Limited coverage drugs – pdp-levetiracetam oral solution

Last updated on September 26, 2024

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Generic name	levetiracetam
Strength	100 mg/mL
Form	Oral Solution

Special Authority criteria	Approval period
Diagnosis of epilepsy PLUS As adjunctive therapy in patients who are refractory to conventional therapy PLUS patient is not able to swallow levetiracetam tablets. Provide supporting details.	1 year
Renewal Confirmation that the patient is not able to swallow levetiracetam tablets	1 year

Special Authority criteria

Approval period

Diagnosis of epilepsy

PLUS

As adjunctive therapy in patients who are refractory to conventional therapy

PLUS

patient is not able to swallow levetiracetam tablets. Provide supporting details.

1 year

Renewal

Confirmation that the patient is not able to swallow levetiracetam tablets

1 year

Practitioner exemptions

No practitioner exemptions

Special notes

None

Special Authority request form(s)

Log in to eForms
5328 - General Special Authority Request (PDF, 656KB)

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Limited coverage drugs – pdp-levetiracetam oral solution

Practitioner exemptions

Special notes

Special Authority request form(s)