Rufinamide (Banzel®)  Prior Authorization Criteria

Rufinamide (Banzel®) Prior Authorization Request Form

Covered Uses

Adjunctive treatment of seizures associated with Lennox-Gastaut syndrome

Exclusion Criteria

• Children less than 4 years old
• Patients with Familial Short QT syndrome

Required Medical Information

Diagnosis of Lennox-Gastaut syndrome

Age Restrictions

Children 4 years and older and adults

Prescriber Restrictions

• Neurologists
• Pediatric neurologists

Coverage Duration

One (1) year

Other Criteria

None