- I. Health Net Approved Indications and Usage Guidelines: 1.Diabetic peripheral neuropathy: A.Diagnosis of diabetic peripheral neuropathy. 2. Postherpetic neuralgia (shingles or herpes zoster): A. Diagnosis of postherpetic neuralgia, AND B. Failure or clinically significant adverse effects to gabapentin. 3. Epilepsy: A. Adjunctive treatment of seizures in adults with epilepsy. 4. Fibromyalgia: A.Diagnosis of fibromyalgia. 5. Neuropathic pain associated with spinal cord injury: A. Diagnosis of pain associated with spinal cord injury. 6. Generalized Anxiety Disorder: A. Diagnosis of Generalized Anxiety Disorder, AND B. Failure or clinically significant adverse effects to TWO of the following alternatives: escitalopram, paroxetine, venlafaxine ER, duloxetine, or buspirone. II. Coverage is Not Authorized For: 1. Dental Pain, essential tremor, osteoarthritis, social phobia III. Authorization Limit : Length of Benefit.
- unspecified ST criteria Step Therapy Exists in PA
- Step Therapy: ST Multiple Generics
- Prior Authorization: Diabetic Peripheral Neuropathy, Post-herpetic Neuralgia:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
Neurology: Epilepsy:
Documented Diagnosis: Yes
Duration: 1 plan year
Reauthorization Required: Yes
- Diabetic Peripheral Neuropathy, Post-herpetic Neuralgia:
Age Requirement: >= 18
Duration: 1 plan year
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Neurology: Epilepsy:
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): Partial-Onset Seizures
Used as Adjunctive Treatment: Yes
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: 2 of Chart Notes;Medication History
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
- Quantity Limit: limit maximum 3 EA PER 1 day(s)
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