Limited Coverage Drugs – Perampanel tablets

Generic Name 

perampanel

Strength

2 mg, 4 mg, 6 mg, 8 mg, 10 mg, 12 mg
Form tablet

Special Authority Criteria

Approval Period

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

  1. as adjunctive therapy (used in combination with at least ONE other anti–epileptic drug) for partial–onset seizures

AND

  1. after at least FOUR 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).

Indefinite

Practitioner Exemptions

  • None

Special Notes

  • Special Authority requests should include documentation stating which other anti-epileptic drugs have been tried in adequate doses. Examples of other anti-epileptic drugs include:
    • phenytoin (Dilantin®)
    • carbamazepine (Tegretol®)
    • gabapentin (Neurontin®)
    • topiramate (Topamax®)
    • lamotrigine (Lamictal®)
    • levetiracetam (Keppra®)
    • lacosamide (Vimpat®)
    • vigabatrin (Sabril®)
    • eslicarbazepine acetate (Aptiom™)
    • valproic acid (Epival®)

Special Authority Request Form(s)