Pharmacy Prior Authorization Criteria

Diacomit (stiripentol)

Indications for Prior Authorization

Diacomit (stiripentol)

• For diagnosis of Dravet syndrome (DS)
  Indicated for the treatment of seizures associated with Dravet syndrome in patients taking clobazam who are 6 months of age or older and weighing 7 kg or more.There are no clinical data to support the use of DIACOMIT as monotherapy in Dravet syndrome.

Criteria

Diacomit

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of seizures associated with Dravet syndrome (DS)
AND
• Used in combination with clobazam
AND
• BOTH of the following:
• Patient is 6 months of age or older
• Patient weighs 7kg or more
AND
• Prescribed by or in consultation with a neurologist

Diacomit

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy
AND
• Used in combination with clobazam

P & T Revisions

2024-05-01, 2023-08-22, 2023-04-10, 2022-08-05, 2022-05-05, 2021-09-27, 2021-05-19, 2020-04-24

References

1. Diacomit Prescribing Information. Biocodex. Gentilly, France. July 2022.

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Revision History

• 2024-05-01: 2024 Annual Review. No criteria changes.
• 2023-08-22: Program update to standard reauthorization language. No changes to clinical intent.
• 2023-04-10: Annual review - no changes to criteria
• 2022-08-05: Guideline Update.
• 2022-05-05: Annual review, inclusion of age requirement
• 2021-09-27: 2021 Annual Review, no changes to criteria.
• 2021-05-19: 2021 Annual Review, no changes to criteria.
• 2020-04-24: 2020 Annual Review, no changes to clinical criteria, removed drug name from reauth criteria.

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