- Prior Authorization: PA_APPLIES
- Quantity Limit: 2 capsules per 1 day(s).
- PA_APPLIES
- Lennox Gastaut Syndrome (LGS):
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Neurology: Epilepsy:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Diagnosis Type(s): Seizures Associated with Lennox-Gastaut Syndrome (LGS)
Used as Adjunctive Treatment: Yes
Duration of Failure or Adjunctive Treatment with Other Antiepileptic Product: Unspecified
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: Yes
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: Yes
|