Trokendi XR — Blue Cross Blue Shield of Alabama

Initial criteria

• ONE of the following: • The patient has a diagnosis of migraine OR • The patient has ONE of the following diagnoses:   – Partial onset seizures OR   – Primary generalized tonic-clonic seizures OR   – Lennox-Gastaut Syndrome OR • The patient has a medication history of use of an anti-seizure medication that is not topiramate OR • The patient has another FDA labeled indication for the requested agent and route of administration OR • The patient has another indication that is supported in compendia for the requested agent and route of administration
• AND If the patient has an FDA labeled indication, then ONE of the following: • The patient’s age is within FDA labeling for the requested indication for the requested agent OR • There is support for using the requested agent for the patient’s age for the requested indication
• AND The patient does NOT have any FDA labeled contraindications to the requested agent
• Compendia Allowed: AHFS or DrugDex 1 or 2a level of evidence

Reauthorization criteria

• Patient has been previously approved for the requested agent through the plan’s Prior Authorization process
• AND ONE of the following: • The patient has had clinical benefit with the requested agent OR • The patient has a medication history of use of an anti-seizure medication that is not topiramate
• AND The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months