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MHCP Enrolled Providers – Pharmacies
Fee-for-Service PA Criteria Sheet – Vimpat
(April 2015)
Drug
Therapeutic Area
Vimpat (lacosamide) tablets and oral suspension
Anti-Seizure, Anti-Epileptic
How Supplied and Dosing
50 mg, 100 mg, 150 mg, 200 mg (and IV infusion, which is not prior authorized)
Oral solution 10 mg/ml
Initial recommended dose 50 mg BID, may be increased weekly by 100 mg/day given as 2 divided doses
up to a daily dose of 200-600 mg/day based on response and tolerance.
FDA approved indication:
Adjunctive therapy for the treatment of partial seizures
Criteria
Vimpat is being used for partial-onset seizures and is being added onto at least one other anti-seizure
therapy AND
 Patient has tried and failed 3 or more anti-epileptic drugs which include: gabapentin, lamotrigine,
levetiracetam, divalproex sodium, oxcarbazepine, topiramate, valproic acid or carbamazepine.
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MHCP Provider Call Center 651-431-2700 or 800-366-5411