I'm a member
You will be redirected to myBlue. Would you like to continue?
Please wait while you are redirected.
Printer Friendly Version
Please perform a formulary drug search on your patient’s member ID to ensure the prescription drug is covered under their benefit plan. The medication(s) in this medical policy may not be covered under a specific member’s benefit plan.
DESCRIPTIONGabitril is indicated as adjunctive therapy in adults and children 12 years and older in the treatment of partial seizures.
Peganone is indicated for the control of tonic-clonic (grand mal) and complex partial (psychomotor) seizures.
POLICYGabitril/Peganone will be approved for individuals that have a history of failure, contraindication, or intolerance to two other anti-epileptic formulary alternatives.
POLICY EXCEPTIONSGabitril/Peganone prior authorization is not required for Federal Employee Program (FEP) and State Health Plan members.
POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY01/01/2014: New policy added.
SOURCE(S)Gabitril® Prescribing Information
Peganone® Prescribing Information
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.