Limited Use Note(s)

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LEVETIRACETAM100mg/mL Oral Sol
Reason For Use CodeClinical Criteria
640For patients unable to swallow or tolerate oral solid dosage forms and who are using this as adjunctive therapy in the treatment of seizure disorders where control by other listed anticonvulsants has been unsatisfactory.
LU Authorization Period: 1 year
705As adjunctive therapy in the treatment of seizure disorders in pediatric patients (less than 18 years of age) where control by other listed anticonvulsants has been unsatisfactory and where the appropriate dose cannot be achieved using listed solid oral levetiracetam dosage formats.
LU Authorization Period: 1 year