Qudexy XR — Blue Cross Blue Shield of Kansas

Lennox-Gastaut Syndrome

Initial criteria

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

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

12 months