PA applies to new starts only.

Clobazam and Sympazan will be approved when BOTH of the following are met:

    1. ONE of the following:

        A. BOTH of the following:

            i. ONE of the following:

                a. There is evidence of a claim that the patient is currently being treated with the requested medication within the past 180 days

OR

                b. The prescriber states the patient is currently being treated with the requested medication

AND

            ii. The patient has an FDA labeled indication or an indication that is supported in CMS approved compendia for the requested medication

OR

        B. BOTH of the following:

        i. The patient has ONE of the following diagnoses:

            a. Seizure disorder

 OR

            b. The patient has an indication that is supported in CMS approved compendia for the requested medication

AND

        ii. The patient does NOT have any FDA labeled contraindications to the requested

medication

AND

    2. ONE of the following:

        A. The requested quantity (dose) does NOT exceed the program quantity limit

OR

        B. ALL of the following:

            i. The requested quantity (dose) is greater than the program quantity limit

AND

            ii. The requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does not exceed the program quantity limit

AND

            iii. The prescriber has provided information in support of therapy with a higher dose for the requested indication

Length of Approval: 12 months