Diacomit — Medical Mutual

Initial criteria

• Patient is age ≥ 6 months and weighs ≥ 7 kg; AND
• Patient meets ONE of the following: (a) Patient is taking concomitant clobazam; OR (b) Patient is unable to take clobazam due to adverse events as determined by the prescriber; 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