Subject: Epidiolex 2609-A SGM P2024

Drug

EPIDIOLEX  (cannabidiol)

Policy:

      I.  INDICATIONS

          The indications below including FDA-approved indications and compendial uses are
          considered a covered benefit provided that all the approval criteria are met and the member
          has no exclusions to the prescribed therapy.

          FDA-Approved Indications
          Epidiolex is indicated for the treatment of seizures associated with Lennox-Gastaut syndrome
          (LGS), Dravet syndrome (DS), or tuberous sclerosis complex (TSC) in patients 1 year of age
          and older.

          All other indications are considered experimental/investigational and not medically necessary.


    II.  CRITERIA FOR INITIAL APPROVAL

          A.  Seizures associated with Lennox-Gastaut syndrome or Dravet syndrome
               Authorization of 12 months may be granted for treatment of seizures associated with
               Lennox-Gastaut syndrome or Dravet syndrome in members 1 year of age and older.

          B.  Seizures associated with Tuberous Sclerosis Complex
               Authorization of 12 months may be granted for treatment of seizures associated with
               tuberous sclerosis complex in members 1 year of age and older.


   III.  CONTINUATION OF THERAPY

          Authorization of 12 months may be granted for continuation of treatment in members (including
          new members) 1 year of age and older requesting reauthorization for an indication listed in
          Section II when the member has achieved or maintained a positive clinical response (e.g.,
          decrease in seizures).

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Epidiolex [package insert]. Palo Alto, CA: Jazz Pharmaceuticals, Inc.; March 2024.

 

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

October 30, 2024