CRITERIA: UPDL Paramount Advantage (Medicaid) APPROVED: 06/2021 VERIFIED: 072021 REVIEWED: 06/2021 ANTICONVULSANTS Prior Authorization Override Request PHARMACY FAX # 844-256-2025 • Pertinent office notes and past medical history must be submitted with the prior authorization request.

PATIENT INFORMATION Patient Name Date

Paramount ID DOB Gender: M/F

Medication Allergies

PROVIDER INFORMATION Prescriber Name NPI # DEA #

Prescriber Specialty Prescriber Address

Office Fax Phone Office Contact Name

MEDICATION REQUESTED Drug Name Strength Directions (Sig)

Duration of Therapy: Quantity Diagnosis Days: Months: Are you requesting brand (DAW): _ NO _ YES *PLEASE NOTE DAW REQUESTS REQUIRE RATIONALE- SEE BELOW

Is the Patient currently being treated with this medication?  Yes; Date started mm/dd/yy / /  No

APTIOM (eslicarbazepine acetate) BANZEL (rufinamide) BRIVIACT (brivaracetam)

CELONTIN (methsuximide) (clobazam – generic of Onfi) (clonazepam ODT – generic of Klonopin wafer) (felbamate – generic of Felbatol) FYCOMPA (perampanel) LAMICTAL ODT (lamotrigine ODT) (lamotrigine ER tablet – generic of Lamictal XR) (levetiracetam ER tablet – Keppra XR) ONFI (clobazam) (oxcarbazepine suspension - generic of Trileptal) OXTELLAR XR (oxcarbazepine ER) PEGANONE (ethotoin) QUDEXY XR (topiramate ER) SABRIL POWDER (vigabatrin) SABRIL TABLET (vigabatrin) SPRITAM (levetiracetam tablet for suspension) STAVZOR (valproic acid DR) SUBVENITE (lamotrigine) SYMPAZAN (clobazam film) (tiagabine – generic of Gabitril) (topiramate ER) (topiramate sprinkle capsule – generic of TROKENDI XR (topiramate) VIMPAT (lacosamide) Topamax) XCOPRI (cenobamate) TEGRETOL CARBATROL TEGRETOL XR TRILEPTAL TABLET TRILEPTAL SUSPENSION KLONOPIN DEPAKOTE DEPAKOTE ER ZARONTIN DILANTIN MYSOLINE DEPAKENE DIASTAT ACUDIAL DIASTAT PEDIATRIC KLONOPIN WAFER (ethotoin) NEURONTIN LAMICTAL KEPPRA LYRICA TOPAMAX ZONEGRAN FELBATOL LAMICTAL XR KEPPRA XR GABITRIL TOPAMAX SPRINKLE CAP

CRITERIA: UPDL Paramount Advantage (Medicaid) APPROVED: 06/2021 VERIFIED: 072021 REVIEWED: 06/2021

MEDICAL JUSTIFICATION: Include Other Relevant Medications Tried and Results Please indicate previous treatment and outcomes below Previous Medication Strength Qty Directions (Sig) Dates (mmddyy to mmddyy) Reason for Discontinuation 1

2

3

4

CRITERIA FOR APPROVAL

1 Has the provider submitted clinical documentation supporting that the patient has taken Yes No the requested drug in the previous 120 days, but does not have a claims history (e.g., new to Medicaid)? [If yes, then no further questions.]

2 Does the requested drug have a corresponding generic that is covered by the state Yes No (without prior approval)? [If no, then skip to question 4.]

3 Has the patient experienced an inadequate treatment response, intolerance, or Yes No contraindication to the generic? [If yes, then no further questions.]

4 Is this request for Fycompa or Vimpat? Yes No [If no, then skip to question 7.]

5 Is the request for continuation of therapy? Yes No [If no, then skip to question 7.]

6 Has the provider submitted clinical documentation and rationale supporting that the Yes No member's disease state is currently controlled on the requested medication? [No further questions.]

7 Is the requested drug being prescribed by or in consultation with a neurologist and the Yes No prescriber’s NPI is of a physician who has registered as a neurology specialist with Ohio Medicaid? [If no, then skip to question 10.]

8 Does the requested drug meet ALL of the following: A) Used only for seizures, B) Is a Yes No tablet or a capsule, C) Does not have an available generic alternative? [If no, then skip to question 10.]

9 Has the patient experienced an inadequate treatment response with a 30-day trial of ONE Yes No preferred medication? [If yes, then no further questions.] [If no, then skip to question 11.]

10 Has the patient experienced an inadequate treatment response with a 30-day trial of at Yes No least TWO preferred medications? [If yes, then no further questions.]

11 Is the patient unable to be changed to preferred medications (which do not require prior Yes No

CRITERIA: UPDL Paramount Advantage (Medicaid) APPROVED: 06/2021 VERIFIED: 072021 REVIEWED: 06/2021 approval) for any of the following acceptable reasons: A) Allergy to TWO preferred medications, B) Contraindication or drug interaction to TWO preferred medications, C) History of unacceptable or toxic side effects to TWO preferred medications?

RELEVANT MEDICAL RATIONALE FOR REQUEST/ADDITIONAL CLINICAL INFORMATION INCLUDING WHY PATIENT REQUIRES BRAND OVER GENERIC. (Attach Relevant Lab Results and Chart Notes)*

*In order to process this request, please complete all boxes completely.

This facsimile and any attached document are confidential and are intended for the use of individual or entity to which it is addressed. If you have received this in error, please notify us by telephone immediately 1-800-891-2520.