Onfi (clobazam) oral tablets and suspension – Brand only — Highmark
Dravet syndrome
Preferred products
- generic clobazam
- valproic acid
- divalproex sodium
- lamotrigine
- topiramate
- rufinamide
Initial criteria
- Criterion A (LGS):
- 1. age ≥ 2 years
- 2. diagnosis of seizures due to Lennox-Gastaut syndrome (ICD-10: G40.81)
- 3. Onfi or Sympazan will be used as adjunctive therapy
- 4. therapeutic failure, contraindication, or intolerance to at least one (1) standard of care plan-preferred product (valproic acid or divalproex sodium, lamotrigine, topiramate, rufinamide)
- 5. If request is for Sympazan, therapeutic failure or intolerance to plan-preferred generic clobazam
- 6. If request is for Onfi, therapeutic failure or intolerance to generic clobazam
- Criterion B (Dravet syndrome):
- 1. diagnosis of Dravet syndrome (ICD-10: G40.83)
- 2. If request is for Sympazan, therapeutic failure or intolerance to plan-preferred generic clobazam
- 3. If request is for Onfi, therapeutic failure or intolerance to generic clobazam
Reauthorization criteria
- Criterion A (LGS):
- 1. age ≥ 2 years
- 2. diagnosis of seizures due to Lennox-Gastaut syndrome (ICD-10: G40.81)
- 3. using Onfi or Sympazan as adjunctive treatment
- 4. prescriber attests to reduction in seizure frequency from baseline
- Criterion B (Dravet syndrome):
- 1. diagnosis of Dravet syndrome (ICD-10: G40.83)
- 2. prescriber attests to reduction in seizure frequency from baseline
Approval duration
12 months