Epidiolex — Blue Cross Blue Shield of New Mexico

seizures associated with Dravet syndrome (DS)

Initial criteria

1. The patient has a diagnosis of seizures associated with ONE of the following: A. Lennox-Gastaut syndrome (LGS) OR B. Dravet syndrome (DS) OR C. Tuberous sclerosis complex (TSC)
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
3. The requested agent will NOT be used as monotherapy for seizure management
4. The patient’s medication history includes the use of an anticonvulsant in the past 90 days
5. The prescriber submitted baseline liver transaminases and total bilirubin levels upon initial review
6. The prescriber will monitor the patient’s liver transaminases while the patient is on the requested agent
7. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
8. The patient does NOT have any FDA labeled contraindications to the requested agent
9. The requested quantity (dose) is within FDA labeled dosing for the requested indication

1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
2. The patient has had clinical benefit with the requested agent
3. The requested agent will NOT be used as monotherapy for seizure management
4. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
5. The patient does NOT have any FDA labeled contraindications to the requested agent
6. The requested quantity (dose) is within FDA labeled dosing for the requested indication

12 months