| UnitedHealthcare |
| Potiga 400 Mg Tab (ezogabine) |
| Drugs for the Nervous System : Drugs for Seizures /Personality Disorder/Nerve Pain |
- Neurology: Epilepsy:
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Used as Adjunctive Treatment: No
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
- Prior Authorization: Neurology: Epilepsy:
PA Applies
- Step Therapy: Neurology: Epilepsy:
ST Single Generic
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