- Step Therapy: Neurology: Epilepsy:
ST Single Generic
- 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:
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Diagnosis Type(s): 1 of Partial-Onset Seizures;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
Supporting Documentation Requirements: Chart Notes
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
- Prior Authorization: Lennox Gastaut Syndrome (LGS):
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
Neurology: Epilepsy:
Documented Diagnosis: Yes
Reauthorization Required: Yes
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