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The Policy VaultThe Policy Vault

Diacomit (stiripentol capsules and powder for oral suspension) — Cigna

Treatment-refractory seizures/epilepsy (specific rare conditions: Lennox-Gastaut syndrome, infantile spasms, tuberous sclerosis complex, Sturge-Weber syndrome, Doose syndrome, infection-related or anoxo-ischemic epilepsy syndromes, cortical malformation/dysplasia, epileptic encephalopathies associated with sodium channel mutations, epilepsy with myoclonic absences)

Initial criteria

  • Patient is age ≥ 6 months and weighs ≥ 7 kg; AND
  • Patient has tried at least two other antiseizure medications; AND
  • The medication is prescribed by or in consultation with a neurologist

Reauthorization criteria

  • Patient is currently receiving Diacomit and is responding to therapy (e.g., reduced seizure severity, frequency, and/or duration) as determined by the prescriber

Approval duration

1 year