Limited Coverage Drug – Special Authority Criteria

Generic Name / Strength / Form

levetiracetam 250, 500, 750 mg tablets


Approval Period

Diagnosis of epilepsy
As adjunctive therapy in patients who are refractory to conventional therapy


Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • None

Special Authority Request Form(s)

Online Forms (PDF, 524KB)
Click on the link to complete a special authority request form.