UnitedHealthcare
Diacomit (stiripentol)
Drugs for the Nervous System : Drugs for Seizures /Personality Disorder/Nerve Pain
  • Dravet Syndrome:
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

    Neurology: Epilepsy:
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    Diagnosis Type(s): Seizures associated with Dravet Syndrome and treated in combination with clobazam (Onfi)
    Used as Adjunctive Treatment: Yes
    Duration of Failure or Adjunctive Treatment with Other Antiepileptic Product: N/A
    Documented history of persisting seizures after titration to highest tolerated dose of each AED.: No
    Lack of compliance as a reason for treatment failure has been ruled out: No
    Documentation of treatment failure due to intolerable side effects.: No
    Positive Response to Therapy Required for Reauth: Yes
    Treatment for Age 17 years or older: No
    Treatment for Age 1-16 years old: No
    History of >= to 30 day trial of other AED required: No
    Reapproval based on response: Yes

  • Prior Authorization: Documented Diagnosis: Yes
    Duration: 12 Month(s)
    Reauthorization Required: Yes