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The Policy VaultThe Policy Vault

Valtoco (diazepam nasal spray) — CareFirst (Caremark)

Acute treatment of intermittent, stereotypic episodes of frequent seizure activity (seizure clusters, acute repetitive seizures) that are distinct from the patient’s usual seizure pattern in patients with epilepsy

Initial criteria

  • The drug is being prescribed for the acute treatment of intermittent, stereotypic episodes of frequent seizure activity (seizure clusters, acute repetitive seizures) that are distinct from the patient’s usual seizure pattern in a patient with epilepsy AND ONE of the following:
  • Requested drug is Libervant (diazepam buccal film) AND patient age is 2 to 5 years
  • Requested drug is Valtoco (diazepam nasal spray) AND patient age is ≥ 2 years

Approval duration

12 months