Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
levetiracetam 250, 500, 750 mg tablets

Criteria Approval Period
Diagnosis of epilepsy
PLUS
As adjunctive therapy in patients who are refractory to conventional therapy		 Indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • None

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