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Diacomit (stiripentol) — Highmark

Dravet syndrome

Preferred products

  • plan-preferred clobazam

Initial criteria

  • A. The member meets all of the following (1 through 5):
  • 1. age 6 months to 2 years
  • 2. weight ≥ 7 kg
  • 3. diagnosis of Dravet Syndrome (ICD-10: G40.83)
  • 4. inadequate response to plan-preferred clobazam monotherapy
  • 5. using Diacomit in combination with clobazam
  • OR
  • B. The member meets all of the following (1 through 4):
  • 1. age ≥ 3 years
  • 2. diagnosis of Dravet Syndrome (ICD-10: G40.83)
  • 3. therapeutic failure, contraindication, or intolerance to all of the following:
  • a. valproic acid or divalproex sodium
  • b. plan-preferred clobazam
  • 4. using Diacomit in combination with clobazam

Reauthorization criteria

  • A. prescriber attests that member has experienced a reduction in seizure frequency
  • B. member is using Diacomit in combination with clobazam

Approval duration

12 months