Onfi — United Healthcare

Initial criteria

• ALL of the following: ONE of the following (Diagnosis of seizures associated with Lennox-Gastaut syndrome (LGS) OR Diagnosis of refractory partial onset seizures (four or more uncontrolled seizures per month after an adequate trial of at least two antiepileptic drugs) OR Diagnosis of Dravet syndrome); BOTH of the following (Used as adjunctive therapy; Not used as primary treatment) OR continuation of prior therapy for a seizure disorder

Reauthorization criteria

• Documentation of positive clinical response to therapy

Approval duration

12 months