- Neurology: Epilepsy:
Duration: 1 plan year
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
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: No
History of >= to 30 day trial of other AED required: No
Reapproval based on response: No
- I. Approved Indications and Usage Guidelines: 1. Brand-name drugs that require prior authorization and generic drug equivalent does not exist: a. Failure or clinically significant adverse effect to two or more (or one if only one exists) formulary alternatives that are FDA approved or standard pharmacopeias (e.g. DrugDex) support efficacy and safety for the requested indication.
- Prior Authorization: Neurology: Epilepsy:
Documented Diagnosis: Yes
Duration: 1 plan year
Reauthorization Required: Yes
- Step Therapy Exists in PA
- Step Therapy: Neurology: Epilepsy:
ST Multiple Generics
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