Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
lacosamide     50mg, 100mg, 150mg, 200mg tablet

Criteria
Approval Period

As last resort adjunctive therapy (used in combination with at least ONE other anti‑epileptic drug) for partial-onset seizures in adults AFTER documented ineffectiveness/intolerance OR contraindications to other available anti-epileptic drugs (see Special Notes below)
Indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • Special Authority requests should include documentation of which other anti-epileptic drugs have been trialed in adequate doses. Examples of other anti-epileptic drugs include:   phenytoin (Dilantin®), carbamazepine (Tegretol®), gabapentin (Neurontin®), topiramate (Topamax®), lamotrigine (Lamictal®), levetiracetam (Keppra®), vigabatrin (Sabril®) and valproic acid (Epival®).

Special Authority Request Forms

Online Forms (PDF)
Click on the link to complete a special authority request form.