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Vigadrone (vigabatrin) — Highmark

Infantile spasms

Preferred products

  • plan-preferred generic vigabatrin packet for oral solution

Initial criteria

  • age 1 month to 2 years
  • diagnosis of infantile spasms (ICD-10: G40.82)
  • using Sabril, Vigadrone, Vigafyde, or Vigpoder as monotherapy
  • if request is for brand Sabril, must have experienced therapeutic failure or intolerance to generic vigabatrin
  • if request is for Vigafyde, must have experienced therapeutic failure or intolerance to plan-preferred generic vigabatrin packet for oral solution

Reauthorization criteria

  • age 1 month to 2 years
  • diagnosis of infantile spasms (ICD-10: G40.82)
  • using Sabril, Vigadrone, Vigafyde, or Vigpoder as monotherapy
  • if request is for brand Sabril, must have experienced therapeutic failure or intolerance to generic vigabatrin
  • if request is for Vigafyde, must have experienced therapeutic failure or intolerance to plan-preferred generic vigabatrin packet for solution
  • prescriber attests that member has experienced a reduction in seizure frequency from baseline

Approval duration

12 months