Medicare AdvantagePrior AuthMedium impact
Diacomit® (stiripentol) (Revised)
Humana·Neurology, Pediatrics, Pharmacy·Medicare Advantage
Effective date
Jan 1, 2023
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has updated its prior authorization policy for Diacomit® (stiripentol) effective January 1, 2023, with a recent revision dated October 22, 2025. The policy requires prior authorization for Diacomit use in Dravet syndrome patients and mandates four specific clinical criteria be met: diagnosed Dravet syndrome with seizures, specialist prescription, documented refractory seizures within 28 days, and concurrent clobazam therapy. Billing teams must ensure all Diacomit claims include prior authorization and verify all four approval criteria are documented before claim submission.
Action Required
By January 31, 2026: Billing team must update prior authorization workflows to enforce the four-part approval criteria for all Diacomit (stiripentol) pharmacy claims under Humana Medicare Advantage plans. Specifically: (1) Verify member has documented diagnosis of Dravet syndrome with seizures; (2) Confirm prescription is from or in consultation with a neurologist or epileptologist; (3) Obtain documentation that member experienced generalized tonic-clonic or clonic seizures within the past 28 days; (4) Verify concurrent clobazam therapy is active. Add these requirements to your prior authorization request forms and billing system rules. Route all Diacomit requests through the Humana PAL portal (www.humana.com/PAL) for preauthorization and notification before dispensing. Train pharmacy and billing staff on these four mandatory criteria. Claims submitted without documented evidence of all four criteria will be denied. Update your EMR/pharmacy system templates to include checkboxes for each criterion.