Vigadrone — CareFirst (Caremark)

Initial criteria

• For infantile spasms: authorization may be granted for treatment of infantile spasms (infantile epileptic spasms syndrome [IESS]) in members less than 2 years of age
• For complex partial seizures (Sabril, vigabatrin, Vigadrone, Vigpoder only): authorization may be granted for treatment of refractory complex partial seizures when member has had an inadequate response to at least two alternative treatments for complex partial seizures

Reauthorization criteria

• For infantile spasms: authorization may be granted when member has shown substantial clinical benefit from vigabatrin therapy
• For complex partial seizures (Sabril, vigabatrin, Vigadrone, Vigpoder only): authorization may be granted when member has shown substantial clinical benefit from vigabatrin therapy

Approval duration

Initial: 4 weeks (infantile spasms) or 3 months (complex partial seizures); Continuation: 6 months (infantile spasms) or 12 months (complex partial seizures)