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Trokendi xr — Blue Cross Blue Shield of Montana

partial onset seizures

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 (AHFS or DrugDex level 1, 2a, or 2b) for the requested agent and route of administration.
  • 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 use in the requested age for the requested indication.
  • 3. The patient does NOT have any FDA labeled contraindications to the requested agent.
  • Additional Approval Options: 1. For BCBS NM Fully Insured or NM HIM member: All of the following: A. No FDA labeled contraindications AND B. Requested indication is a rare disease AND C. One of: another FDA labeled indication OR another compendia supported indication (DrugDex level 1, 2A, or 2B; AHFS-DI supportive narrative). 2. For OH Fully Insured or HIM Shop (SG) members: All of the following: A. Member resides in Ohio AND B. Plan is Fully Insured/HIM Shop AND C. No FDA labeled contraindications AND D. One of: another FDA labeled indication OR another compendia supported indication OR prescriber provides two peer-reviewed journal articles supporting use (acceptable designs include randomized, double-blind, placebo-controlled clinical trials; case studies not acceptable).

Reauthorization criteria

  • 1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization process.
  • 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.
  • 3. The patient does NOT have any FDA labeled contraindications to the requested agent.

Approval duration

12 months