UnitedHealthcare
Fycompa (Dspk) (perampanel)
Drugs for the Nervous System : Drugs for Seizures /Personality Disorder/Nerve Pain
  • Prior Authorization: Neurology: Epilepsy:
    Documented Diagnosis: Yes
    Duration: 12 Month(s)

  • Neurology: Epilepsy:
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Diagnosis Type(s): 1 of Partial-Onset Seizures;Primary Generalized Tonic-Clonic Seizures
    Used as Adjunctive Treatment: No
    Duration of Failure or Adjunctive Treatment with Other Antiepileptic Product: >= 8 week(s)
    Documented history of persisting seizures after titration to highest tolerated dose of each AED.: Yes
    Lack of compliance as a reason for treatment failure has been ruled out: Yes
    Documentation of treatment failure due to intolerable side effects.: Yes
    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

  • Step Therapy: Neurology: Epilepsy:
    ST Multiple Generics

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