Medical Policy

Effective Date:07/01/2016 Title:Sabril (Vigabatrin)
Revision Date: Document:BI514:00
CPT Code(s):None
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Sabril (Vigabatrin) tablets and powder for oral solution require prior authorization.

2)    Sabril is used in the treatment of infantile spasms and seizures.

Medical Statement

Sabril (Vigabatrin) is considered medically necessary for the following conditions, subject to the criteria stated below:

 

Infantile Spasms

1)    Patient is > 1 month to 2 years of age AND

2)    Patient has a diagnosis of infantile spasms

 

Refractory Complex Partial Seizures

1)    Patient is > 10 years of age AND

2)    Patient has a diagnosis of complex partial seizures AND

3)    Patient has responded inadequately to at least two generic first-line agents (carbamazepine, lamotrigine, Levetiracetam, oxcarbazeine, Valproic acid/divalproex sodium).

Limits
Intentially left empty
Reference

1)    Sabril Package Insert. September 2015.

2)    Clinical Pharmacology. Accessed online April 29, 2016.

Application to Products

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.


Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.