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The Policy VaultThe Policy Vault

Diacomit — Medical Mutual

Treatment-Refractory Seizures/Epilepsy (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