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Epidiolex Prior Authorization Criteria - Medicare Part D
Prior Authorization Criteria for Approval
PA applies to new starts only.
Epidiolex will be approved when ALL of the following are met:
- The patient has a diagnosis of seizures associated with ONE of the following:
- Lennox-Gastaut syndrome OR
- Dravet syndrome OR
- Tuberous sclerosis complex AND
- The patient is within the FDA labeled age for the requested medication AND
- The requested dose is within FDA labeled dosing for the requested indication
Length of Approval: 12 months
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