Limited coverage criteria – pdp-levetiracetam oral solution

Last updated on March 20, 2025

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Generic name	levetiracetam
Strength & form	100 mg/mL oral solution

Special Authority criteria	Approval period
Initial Diagnosis of epilepsy AND As adjunctive therapy in patients who are refractory to conventional therapy AND 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

Initial

Diagnosis of epilepsy

AND

As adjunctive therapy in patients who are refractory to conventional therapy

AND

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
HLTH 5328 – General Special Authority request (PDF, 656KB)

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