Epidiolex (cannabidiol oral solution) — Highmark
Lennox-Gastaut syndrome (LGS)
Preferred products
- valproic acid
- divalproex sodium
- topiramate
- lamotrigine
- clobazam
Initial criteria
- age ≥ 1 year
- diagnosis of Lennox-Gastaut syndrome (ICD-10: G40.81)
- treatment is in combination with other conventional agents
- therapeutic failure, contraindication, or intolerance to at least two of the following plan-preferred generic products: valproic acid or divalproex sodium, topiramate, lamotrigine, clobazam
Reauthorization criteria
- prescriber attests that the member has experienced a reduction in seizure frequency from baseline
Approval duration
12 months