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Drugstiripentol (Diacomit) [Biocodex]

July 2017

Therapeutic Area - Antiepileptic

Approval criteria

Stiripentol may be covered by Minnesota Health Care Programs (MHCP) if ALL of the following conditions are met:

  • At the time of request, patient is 20 years of age or younger AND
  • At the time of request, patient must be eligible for Fee-for-Service Medical Assistance AND
  • At time of request, the prescriber must submit a letter of medical necessity along with the prior authorization request AND
  • Patient must have a documented diagnosis of Dravet syndrome OR
  • Patient must have documented diagnosis of malignant migrating partial epilepsy in infancy (MMPSI) due to an SCN2A genetic mutation AND
  • Prescriber must provide a list of medications that have been tried without successful outcomes AND
  • Prescriber must provide documentation that the United States Food and Drug Administration (US FDA) has approved the patient investigational new drug (IND) application for the use of stiripentol

Renewal criteria

  • Prior authorization must be requested annually AND
  • Patient must meet ALL approval criteria 


MN Statute 256B.0625 subd. 64 and MN Medicaid State Plan Amendment grant the Department Human Services the authority to cover stiripentol for MHCP’s qualified recipients. Stiripentol is not approved by the US FDA to be safe and effective for any indication. MHCP’s qualified recipients must obtain stiripentol through Caligor Rx Pharmacy based in New York according to FDA’s Policy on Importation of Drugs.


MHCP Provider Call Center 651-431-2700 or 800-366-5411

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