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 and valproate

AND

Documented inadequate response to levetiracetam OR topiramate

AND

Stiripentol must be prescribed by a neurologist

Indefinite

Practitioner Exemptions

  • None

Special Notes

  • None

Special Authority Request Form(s)