- Quantity Limit: 6 packets per 1 day(s).
- Dravet Syndrome, Lennox Gastaut Syndrome (LGS):
Age Requirement: >= 1
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Neurology: Epilepsy:
Age Requirement: >= 1
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Diagnosis Type(s): 1 of Dravet syndrome;Seizure associated with tuberous sclerosis;Seizures Associated with Lennox-Gastaut Syndrome (LGS)
Used as Adjunctive Treatment: No
Duration of Failure or Adjunctive Treatment with Other Antiepileptic Product: N/A
Documented history of persisting seizures after titration to highest tolerated dose of each AED.: No
Lack of compliance as a reason for treatment failure has been ruled out: No
Documentation of treatment failure due to intolerable side effects.: No
Positive Response to Therapy Required for Reauth: No
Treatment for Age 17 years or older: No
Treatment for Age 1-16 years old: Yes
History of >= to 30 day trial of other AED required: No
Reapproval based on response: No
- Prior Authorization: PA_APPLIES
- 1;
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