Limited coverage criteria – rufinamide

Last updated on March 21, 2025

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Generic name		rufinamide
Strength & form		100 mg/200 mg/400 mg tablet

Special Authority criteria	Approval period
For the treatment of Lennox-Gastaut syndrome (LGS) when prescribed by a neurologist as adjunctive therapy in a patient who is currently taking at least two other anti‑epileptic drugs	Indefinite

Special Authority criteria

Approval period

For the treatment of Lennox-Gastaut syndrome (LGS) when prescribed by a neurologist as adjunctive therapy in a patient who is currently taking at least two other anti‑epileptic drugs

Indefinite

Practitioner exemptions

None

Special notes

None

Special Authority request form(s)

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

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