Limited Coverage Drugs – brivaracetam

Generic Name

brivaracetam

Strength

10 mg, 25 mg, 50 mg, 75 mg and 100 mg

Form

tablet

Special Authority Criteria

Approval Period

For the treatment of partial-onset seizures in adults, and to be:

  1. Used as adjunctive therapy (used in combination with at least TWO other anti–epileptic medications) for partial-onset seizures

AND

  1. Used after at least TWO other anti-epileptic medications have been tried without success (names of previously tried therapies and response must be indicated on Special Authority request; see Special Notes below)

AND

  1. NOT used concurrently with levetiracetam

Indefinite

Practitioner Exemptions

  • None

Special Notes

Special Authority requests should include documentation stating which other anti-epileptic drugs have been tried in adequate doses. Two trialed products must be described in the request for coverage in order for coverage to be considered for brivaracetam.

Examples of other anti-epileptic drugs include:

  • phenytoin (Dilantin®)
  • carbamazepine (Tegretol®)
  • gabapentin (Neurontin®)
  • topiramate (Topamax®)
  • lamotrigine (Lamictal®)
  • levetiracetam (Keppra®)
  • perampanel (Fycompa™)
  • vigabatrin (Sabril®)
  • eslicarbazepine acetate (Aptiom™)
  • valproic acid (Epival®)

Special Authority Request Form(s)