COVERED USES:

FDA-Approved Indications:

Adjunctive treatment of seizures associated with Lennox-Gastaut syndrome in children 4 years and older and adults.

All FDA approved indications not otherwise excluded from Part D.

AGE RESTRICTIONS:

NA

PRESCRIBER RESTRICTIONS:

NA

REQUIRED MEDICAL INFORMATION:

For initiation of treatment, a prior authorization form and relevant chart notes documenting medical rationale are required and for continuation of therapy, ongoing documentation of successful response to the medication may be necessary.

CRITERIA:

• The member is already established on therapy
OR
• The condition being treated meets the "Covered Uses" criteria above

EXCLUSION CRITERIA:

Banzel will not be covered for treatment of neuropathic pain.

COVERAGE DURATION:

Initial authorization and reauthorization will be approved for up to one year.