Prior Auth Protocol

FDA Approved Indications:

Adjunctive therapy in patients ≥2 years of age for partial seizures, primary generalized tonic-clonic seizures, and generalized seizures of Lennox-Gastaut syndrome.
Monotherapy in patients ≥16 years of age: conversion to monotherapy in patients with partial seizures who are receiving treatment with carbamazepine, phenobarbital, phenytoin, primidone, or valproate as the single antiepileptic drug.
Bipolar Disorder: maintenance treatment of Bipolar I Disorder to delay the time to occurrence of mood episodes (depression, mania, hypomania, mixed episodes) in patients treated for acute mood episodes with standard therapy.

Health Net Approved Indications and Usage Guidelines:

Member has a documented swallowing disorder or an inability to swallow tablets or capsules

Coverage is Not Authorized For:

Non-FDA approved indications, which are not listed in the Health Net Approved Indications and Usage Guidelines section, unless there is sufficient documentation of efficacy and safety in the published literature

General Information:

Therapeutic Alternatives:

Drug	Dosing Regimen	Dose Limit/ Maximum Dose
lamotrigine immediate release (Lamictal^R)	25 to 500 mg PO QD, divided doses	400 to 500 mg PO QD, in divided doses

* Requires Prior Authorization

Recommended Dosing Regimen and Authorization Limit:

Drug	Dosing Regimen	Authorization Limit
Lamictal ODT (lamotrigine orally disintegrating tablets)	25 to 500 mg PO QD, in divided doses	Length of Benefit

Product Availability:

Orally Disintegrating Tablets: 25 mg, 50 mg, 100 mg, and 200 mg.

Titration Blue Kit for Patients Taking Valproate: 25 mg (21) & 50 mg (7)

Titration Green Kit for Patients Taking Carbamazepine, Phenytoin, Phenobarbital, or Primidone and Not Taking Valproate: 50 mg (42) & 100 mg (14)

Titration Kit for Patients Not Taking Carbamazepine, Phenytoin, Phenobarbital, Primidone, or Valproate: 25 mg (14) & 50 mg (14) & 100 mg (7)

References:

Lamictal ODT [Prescribing Information] GlaxoSmithKline, Research Triangle Park, NC. May, 2015
Micromedex^R Healthcare Series [Internet database]. Greenwood Village, Colo: Thomson Healthcare. Updated periodically. Accessed June, 08, 2015 .
Lamictal. American Hospital Formulary Service Drug Information. Available at: http://www.medicinescomplete.com/mc/ahfs/current/. Accessed June, 08, 2015 .