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Epidiolex and Diacomit Clinical Prior Authorization Criteria Updates

Last updated on 9/15/2020

The Vendor Drug Program (VDP) regularly updates the clinical prior authorization criteria. These updates are necessary to help align VDP drug policies and prior authorization approval criteria with the latest information available on drug information packets and federal or state regulations.

On October 1, 2020, International Classification of Diseases, (ICD-10) code G40.83 becomes available for Dravet Syndrome with the following sub-codes:

  • 833 for Dravet Syndrome, interactable with status epilepticus.
  • 834 for Dravet Syndrome, interactable without status epilepticus.

The revised criteria document is available for review.

On July 31, 2020, the Food and Drug Administration (FDA) approved Epidiolex for the treatment of seizures associated with tuberous sclerosis complex in patients one year of age and older. The revised criteria document with this new indication is available for review.

Both clinical prior authorizations are optional for the managed care organizations (MCOs) to implement. The Pharmacy Clinical Prior Authorization Assistance Chart shows the prior authorization each MCO uses and how those authorizations relate to the authorizations used for traditional Medicaid claim processing. This chart is updated quarterly.

Providers can contact with any comments or questions.