- Dravet Syndrome:
Age Requirement: >= 2
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Neurologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Neurology: Epilepsy:
Age Requirement: >= 2
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Neurologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Diagnosis Type(s): Dravet syndrome
Used as Adjunctive Treatment: Yes
Duration of Failure or Adjunctive Treatment with Other Antiepileptic Product: >= 3 month(s)
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: Yes
History of >= to 30 day trial of other AED required: No
Reapproval based on response: Yes
- Prior Authorization: Documented Diagnosis: Yes
Age Requirement: >= 2
Duration: 1 plan year
Reauthorization Required: Yes
- Quantity Limit: limit maximum 12 EA PER 1 day(s)
- Step Therapy: Neurology: Epilepsy:
ST Single Brand
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