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Banzel — CareFirst (Caremark)

Adjunctive treatment of seizures associated with Lennox-Gastaut Syndrome (LGS)

Initial criteria

  • If the request is for Banzel (rufinamide): patient age ≥ 1 year.
  • If the request is for Onfi (clobazam) OR Sympazan (clobazam): patient age ≥ 2 years.

Reauthorization criteria

  • If the request is for Banzel (rufinamide): patient age ≥ 1 year.
  • If the request is for Onfi (clobazam) OR Sympazan (clobazam): patient age ≥ 2 years.
  • Patient has achieved and maintained positive clinical response as evidenced by reduction in frequency or duration of seizures compared with seizure activity prior to initiation of the requested drug.

Approval duration

36 months