Limited Coverage Drugs - Stiripentol

Generic Name

stiripentol

Strength

250 mg capsule

500 mg capsule

250 mg/pack powder for suspension

500 mg/pack powder for suspension

Form

capsule

pack powder for suspension

Special Authority Criteria

Approval Period

Diagnosis of severe myoclonic epilepsy in infancy (Dravet syndrome)

AND

As adjunctive therapy in combination with clobazam and valproate

AND

Documented inadequate response to clobazam, valproate,  levetiracetam and topiramate

AND

Stiripentol must be prescribed by a neurologist.

Indefinite

 

Practitioner Exemptions

  • None

Special Notes

  • None

Special Authority Request Form(s)