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Limited coverage criteria – brivaracetam

Last updated on March 17, 2025

 

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Generic name

brivaracetam

Strength & form

10 mg, 25 mg, 50 mg, 75 mg, 100 mg tablet

Special Authority criteria

Approval period

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

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

AND

  • 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

  • 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 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)