will apply to all services performed on or after the above revision date which
will become the new effective date.
services referred to in this policy that were performed before the revision
date, contact customer service for the rules that would apply.
(Clobazam) requires prior authorization.
(Clobazam) is covered as adjunct therapy to other anticonvulsants in the
treatment of Lennox-Gastaut syndrome in patients 2 years of age and older.
Onfi is not
covered for other uses.
covered under the pharmacy benefit.