Limited coverage criteria – lacosamide

 

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Generic name		lacosamide
Strength & form		50mg, 100mg, 150mg, 200mg 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 ONE other anti-epileptic drug) AND 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)	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:
  • Carbamazepine
  • Clobazam
  • Gabapentin
  • Lamotrigine
  • Levetiracetam
  • Phenytoin
  • Topiramate
  • Vigabatrin
  • Valproic acid

Special Authority request form(s)

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