Limited coverage criteria – cenobamate

 

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Generic name		cenobamate
Strength & form		12.5 mg, 25 mg, 50 mg, 100 mg, 150 mg, 200 mg tablet

Special Authority criteria	Approval period
For the treatment of partial-onset seizures in adults ( ≥ 18 years of age) and to be used: As adjunctive therapy (used in combination with at least ONE other anti-epileptic drug) AND 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)	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 may include:
  • carbamazepine (Tegretol^®)
  • clobazam (Frisium^®)
  • gabapentin (Neurontin^®)
  • lacosamide (Vimpat^®)
  • lamotrigine (Lamictal^®)
  • levetiracetam (Keppra^®)
  • phenytoin (Dilantin^®)
  • topiramate (Topamax^®)
  • vigabatrin (Sabril^®)
  • valproic acid (Epival^®)

Special Authority requests

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• HLTH 5328 – General Special Authority request (PDF, 656KB)