Sabril (vigabatrin) — Highmark
Refractory complex partial seizures (focal impaired awareness seizures)
Preferred products
- generic vigabatrin
Initial criteria
- age ≥ 2 years
- diagnosis of refractory complex partial seizures (ICD-10: G40.21)
- using Sabril, Vigadrone, or Vigpoder as adjunctive therapy
- experienced therapeutic failure, contraindication, or intolerance to two alternative generic anticonvulsants
- if request is for brand Sabril, must have experienced therapeutic failure or intolerance to generic vigabatrin
Reauthorization criteria
- age ≥ 2 years
- diagnosis of refractory complex partial seizures (ICD-10: G40.21)
- using Sabril, Vigadrone, or Vigpoder as adjunctive therapy
- if request is for brand Sabril, must have experienced therapeutic failure or intolerance to generic vigabatrin
- prescriber attests that member has experienced a reduction in seizure frequency from baseline
Approval duration
12 months