Limited Use Note(s)

CENOBAMATE25mg Tab

Reason For Use Code	Clinical Criteria
719	As adjunctive therapy in the treatment of patients with partial onset seizures (POS) who have had an inadequate response or have significant intolerance to at least 2 other less costly anticonvulsant therapies (prior or current use); AND Patients are under the care of a physician experienced in the treatment of epilepsy. Note: Less costly anticonvulsant therapies may include the following: Phenytoin, Carbamazepine, Gabapentin, Lamotrigine, Vigabatrin, Topiramate, etc.
	LU Authorization Period: Indefinite

Reason For Use Code

Clinical Criteria

719

As adjunctive therapy in the treatment of patients with partial onset seizures (POS) who have had an inadequate response or have significant intolerance to at least 2 other less costly anticonvulsant therapies (prior or current use); AND Patients are under the care of a physician experienced in the treatment of epilepsy. Note: Less costly anticonvulsant therapies may include the following: Phenytoin, Carbamazepine, Gabapentin, Lamotrigine, Vigabatrin, Topiramate, etc.

LU Authorization Period: Indefinite

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