Limited coverage criteria – levetiracetam

Last updated on March 19, 2025

Special Authority requests can now be submitted online. It's simple and quick!

This drug is eligible for automatic approval when patient meets criteria and the request is submitted through eForms

Generic name	levetiracetam
Strength & form	250 mg, 500 mg, 750 mg, 1000 mg tablet

Special Authority criteria	Approval period
Diagnosis of epilepsy PLUS As adjunctive therapy in patients who are refractory to conventional therapy	Indefinite

Special Authority criteria

Approval period

Diagnosis of epilepsy

PLUS

As adjunctive therapy in patients who are refractory to conventional therapy

Indefinite

Practitioner exemptions

No practitioner exemptions

Special notes

None

Special Authority request form(s)

Log in to eForms
HLTH 5328 – General Special Authority request (PDF, 656KB)

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