STIRIPENTOL

STIRIPENTOL (12088F)

stiripentol 500 mg powder for oral liquid, 60 sachets
12088F
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 17456)

Indication: Severe myoclonic epilepsy in infancy (Dravet syndrome)
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 120 # of repeats: 3 DPMQ: $1,296.24 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Diacomit

STIRIPENTOL (12103B)

stiripentol 250 mg capsule, 60
12103B
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 17456)

Indication: Severe myoclonic epilepsy in infancy (Dravet syndrome)
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 120 # of repeats: 3 DPMQ: $670.36 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Diacomit

STIRIPENTOL (12106E)

stiripentol 250 mg powder for oral liquid, 60 sachets
12106E
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 17456)

Indication: Severe myoclonic epilepsy in infancy (Dravet syndrome)
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 120 # of repeats: 3 DPMQ: $670.36 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Diacomit

STIRIPENTOL (12107F)

stiripentol 500 mg capsule, 60
12107F
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 17456)

Indication: Severe myoclonic epilepsy in infancy (Dravet syndrome)
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 120 # of repeats: 3 DPMQ: $1,296.24 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Diacomit