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Sympazan™ - NC Standard

Commercial Policy
Version Date: September 2020

Restricted Product(s)

  • Sympazan™

FDA Approved Use

  • For adjunctive treatment of seizures associated with Lennox-Gastaut Syndrome (LGS) in patients 2 years of age or older.

Criteria for Approval of Restricted Product(s)

  1. The patient is currently taking Sympazan for seizure control and is stable on therapy; OR 
  2. The patient has been diagnosed with Lennox-Gastaut syndrome; AND
  3. The patient has had a trial and failure of generic clobazam; OR 
  4. The patient has a documented allergy, intolerance, or clinical contraindication to generic clobazam; AND 
  5. For formularies that exclude (non-formulary) the requested medication, Non-formulary Exception Criteria applies.

Duration of Approval: 1095 days (3 years)

References

All information referenced is from FDA package insert unless otherwise noted below.

Policy Implementation/Update Information

Sept 2020: Annual criteria review. Format changes. Removed unrestricted alternatives list.
Nov 2018: Original utilization management policy issued

Disclosures:

BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross NC is an independent licensee of the Blue Cross and Blue Shield Association. All other marks are the property of their respective owners.

Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.

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