Sympazan (clobazam) — CareFirst (Caremark)

Initial criteria

• The requested drug is being prescribed for adjunctive treatment of seizures associated with Lennox-Gastaut Syndrome
• If the request is for Banzel (rufinamide), the patient is age ≥ 1 year
• If the request is for Onfi (clobazam) OR Sympazan (clobazam), the patient is age ≥ 2 years

Reauthorization criteria

• The requested drug is being prescribed for adjunctive treatment of seizures associated with Lennox-Gastaut Syndrome
• If the request is for Banzel (rufinamide), the patient is age ≥ 1 year
• If the request is for Onfi (clobazam) OR Sympazan (clobazam), the patient is age ≥ 2 years
• The 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