Limited Coverage Drugs – Rufinamide

Generic Name

rufinamide

Strength

100 mg, 200 mg, 400 mg
Form tablet
Special Authority Criteria Approval Period

For the treatment of Lennox-Gastaut syndrome (LGS) when prescribed by a neurologist as adjunctive therapy in a patient who is currently taking at least two other anti‑epileptic drugs.

 

Indefinte

Practitioner Exemptions

  • None

Special Notes

  • None

Special Authority Request Form