Prior Auth Protocol

FDA Approved Indications:

Adults: Adjunctive therapy in the treatment of partial seizures
Children: Adjunctive therapy in the treatment of partial seizures in children 6 to 17 years

Health Net Approved Indications and Usage Guidelines:

AND

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:

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Therapeutic Alternatives:

Drug	Dosing Regimen	Dose Limit/ Maximum Dose
Trileptal (oxcarbazepine)	Children 8-10 mg/kg PO not to exceed 600 mg/day BID Children 2 to less than 4 years 16-20 mg/kg PO not to exceed 600 mg/day may be considered Adults 300 mg PO BID not to exceed 2,400 mg/day	Children 600 mg/day Adults 2,400 mg/day

* Requires Prior Authorization

Recommended Dosing Regimen and Authorization Limit:

Drug	Dosing Regimen	Authorization Limit
Oxtellar XR	Adults Initiate with a dose of 600 mg PO QD. Dose increases can be made at weekly intervals in 600 mg PO/day increments to achieve 1200 mg to 2400 mg/day. Children Target dose is based upon weight. Titrate to target dose over two to three weeks. Initiate with 8 mg/kg to 10 mg/kg PO QD. Increase in weekly increments of 8 mg/kg to 10 mg/kg once daily, not to exceed 600 mg. To achieve target daily dose: 20 kg to 29 kg: 900 mg per day 29.1 kg to 39 kg: 1200 mg per day greater than 39 kg: 1800 mg per day	Length of Benefit

Product Availability:

Extended-release tablets: 150 mg, 300 mg and 600 mg

References:

Interim Guidelines; Final Review and Approval by the P&T Committee Pending