Sympazan (clobazam) oral film — Highmark

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