UnitedHealthcare
Epidiolex (cannabidiol)
Drugs for the Nervous System : Drugs for Seizures /Personality Disorder/Nerve Pain
  • Dravet Syndrome, Lennox Gastaut Syndrome (LGS):
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

    Neurology: Epilepsy:
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Diagnosis Type(s): 1 of Dravet syndrome;Seizure associated with tuberous sclerosis;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.: 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

  • Step Therapy: ST Multiple Generics

  • Prior Authorization: Documented Diagnosis: Yes
    Duration: 12 Month(s)