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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
Online Forms (PDF)
Click on the link to complete a special authority request form.
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Last Revised: June 21, 2006
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