Diacomit — CareFirst (Caremark)
Seizures associated with Dravet syndrome
Initial criteria
- Member has a diagnosis of seizures associated with Dravet syndrome
- Member is age ≥ 6 months
- Member weighs ≥ 7 kg
- Member is taking clobazam concurrently with another anti-seizure medication
- Requested medication will not be used as monotherapy in Dravet syndrome
Reauthorization criteria
- Member continues to have a diagnosis of seizures associated with Dravet syndrome
- Member is age ≥ 6 months
- Member has achieved or maintained a positive clinical response (e.g., decrease in seizure frequency)
- Member is taking clobazam concurrently with another anti-seizure medication
- Requested medication will not be used as monotherapy in Dravet syndrome
Approval duration
12 months