Limited coverage criteria – stiripentol

stiripentol

250 mg/500 mg capsule

250 mg/500 mg pack powder for suspension

Diagnosis of severe myoclonic epilepsy in infancy (Dravet syndrome)

AND

As adjunctive therapy in combination with clobazam and valproate

AND

Documented inadequate response to clobazam and valproate

AND

Documented inadequate response to levetiracetam OR topiramate

AND

A Special Authority request has been submitted by a neurologist

Indefinite