- Quantity Limit: limit maximum 3 EA PER fill retail
- Prior Authorization: Antiviral: Hepatitis C (HCV):
Documented Diagnosis: Yes
Age Requirement: >= 3
- Dravet Syndrome:
Age Requirement: >= 2
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Neurologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
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): 1 of Complex Partial (Pychomotor) Seizures;Dravet syndrome;Intractable 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.: Yes
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: Yes
History of >= to 30 day trial of other AED required: No
Reapproval based on response: Yes
|