AvMed Anticonvulsant Prior Auth Policy Update

Coverage Criteria for Anticonvulsant Medications

Oxtellar XR / Trileptal (oxcarbazepine) — drug-specific criteria

Member must select ONE of the following medications and indications for use:

ALL of the following

For Trileptal requests: Member is 2 years of age or older and has a confirmed diagnosis of partial-onset seizures.
For Oxtellar XR requests: Member is 6 years of age or older and has a confirmed diagnosis of partial-onset seizures.
For generic oxcarbazepine extended-release (Oxtellar XR)
- Member has had an insufficient response or intolerance with generic immediate-release oxcarbazepine
- AND at least ONE of the following medications has been tried and failed (please note all that have been tried and failed): carbamazepine/ER, divalproex sodium ER/DR, felbamate (PA required), gabapentin, lacosamide, lamotrigine/ER, levetiracetam/ER, phenobarbital, phenytoin, pregabalin, primidone, tiagabine (PA required), topiramate/ER, valproic acid/valproate, zonisamide.
For brand Oxtellar XR or Trileptal
- Provider must submit documentation that therapy with generic immediate-release oxcarbazepine has been insufficient.
- Member has had an insufficient response or intolerance to at least TWO additional of the following medications (please note all that have been tried and failed): carbamazepine/ER, divalproex sodium ER/DR, felbamate (PA required), gabapentin, lacosamide, lamotrigine/ER, levetiracetam/ER, phenobarbital, phenytoin, pregabalin, primidone, tiagabine (PA required), topiramate/ER, valproic acid/valproate, zonisamide.

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Prior authorization (PA) is required for the anticonvulsant products listed on this PA/step-edit request. The prescribing physician must sign and clearly print their name (preprinted stamps are not valid). Fax completed PA form and supporting documentation to AvMed at 1-305-671-0200. Authorizations may be delayed or denied if information is incomplete, incorrect, illegible, or required documents are missing.

Fax: 1-305-671-0200
Prescriber signature required (no preprinted stamps)

Documentation Required

Required Submission Elements

Required submission elements: Complete member and prescriber information and drug details on the PA form. Include member name, AvMed ID#, date of birth; prescriber name, NPI, prescriber signature and date; office contact name, phone and fax number. Provide drug name, form/strength, dosing schedule, diagnosis and ICD-10 code (if applicable), weight and date weight obtained (when relevant), length of therapy, and whether request is for brand or generic.

Step Therapy Documentation and Prior Trials

Drug / Product	Required prior trials (document agents tried and failed)
Aptiom (eslicarbazepine) - generic	Insufficient response or intolerance to oxcarbazepine AND at least TWO of: carbamazepine/ER; divalproex sodium ER/DR; felbamate (PA required); gabapentin; lacosamide; lamotrigine/ER; levetiracetam/ER; oxcarbazepine; phenobarbital; phenytoin; pregabalin; primidone; tiagabine (PA required); topiramate/ER; valproic acid/valproate; zonisamide
Aptiom (eslicarbazepine) - brand	Documentation that generic eslicarbazepine was insufficient AND insufficient response or intolerance to oxcarbazepine AND at least TWO additional of the agents listed for generic
Banzel (rufinamide) - generic	Insufficient response or intolerance to at least TWO of: clobazam; clonazepam; felbamate (PA required); lamotrigine; topiramate
Banzel (rufinamide) - brand	Insufficient response or intolerance to generic rufinamide AND at least TWO of: clobazam; clonazepam; felbamate (PA required); lamotrigine; topiramate
Briviact (brivaracetam) - generic	Insufficient response or intolerance to levetiracetam AND at least TWO of: carbamazepine/ER; divalproex sodium ER/DR; felbamate (PA required); gabapentin; lacosamide; lamotrigine/ER; levetiracetam/ER; oxcarbazepine; phenobarbital; phenytoin; pregabalin; primidone; tiagabine (PA required); topiramate/ER; valproic acid/valproate; zonisamide
Briviact (brivaracetam) - brand	Documentation that generic brivaracetam was insufficient AND insufficient response or intolerance to at least THREE of the agents listed for generic
Felbatol (felbamate) - generic/brand	Member MUST have had an insufficient response or intolerance to at least THREE of: carbamazepine/ER; divalproex sodium ER/DR; gabapentin; lacosamide; lamotrigine/ER; levetiracetam/ER; oxcarbazepine; phenobarbital; phenytoin; pregabalin; primidone; tiagabine (PA required); topiramate/ER; valproic acid/valproate; zonisamide (brand also requires documentation of generic failure)
Fycompa (perampanel) - generic	Insufficient response or intolerance to at least THREE of: carbamazepine/ER; divalproex sodium ER/DR; felbamate (PA required); gabapentin; lacosamide; lamotrigine/ER; levetiracetam/ER; oxcarbazepine; phenobarbital; phenytoin; pregabalin; primidone; tiagabine (PA required); topiramate/ER; valproic acid/valproate; zonisamide
Fycompa (perampanel) - brand	Documentation that generic perampanel was insufficient AND insufficient response or intolerance to at least THREE of the agents listed for generic
Tiagabine (Gabitril) - (PA required)	Insufficient response or intolerance to at least THREE of: carbamazepine/ER; divalproex sodium ER/DR; felbamate (PA required); gabapentin; lacosamide; lamotrigine/ER; levetiracetam/ER; oxcarbazepine; phenobarbital; phenytoin; pregabalin; primidone; topiramate/ER; valproic acid/valproate; zonisamide
Keppra (levetiracetam) - brand	Provider has submitted documentation that therapy with generic immediate‑release levetiracetam has been insufficient (age/diagnosis-specific requirements apply)
Keppra XR (levetiracetam) - brand	Provider has submitted documentation that therapy with generic extended‑release levetiracetam has been insufficient (age/diagnosis-specific requirements apply)
Lamictal (lamotrigine) - brand	Provider has submitted documentation that therapy with generic immediate‑release lamotrigine has been insufficient (indication-specific requirements apply)
Mysoline (primidone) - brand	Provider has submitted documentation that therapy with primidone has been insufficient
Oxtellar XR (oxcarbazepine ER) - generic	Insufficient response or intolerance to generic immediate‑release oxcarbazepine AND at least ONE of: carbamazepine/ER; divalproex sodium ER/DR; felbamate (PA required); gabapentin; lacosamide; lamotrigine/ER; levetiracetam/ER; phenobarbital; phenytoin; pregabalin; primidone; tiagabine (PA required); topiramate/ER; valproic acid/valproate; zonisamide
Oxtellar XR or Trileptal (oxcarbazepine) - brand	Documentation that generic immediate‑release oxcarbazepine was insufficient AND insufficient response or intolerance to at least TWO additional of the agents listed for generic
Xcopri (cenobamate) - generic/brand	Insufficient response or intolerance to at least THREE of: carbamazepine/ER; divalproex sodium ER/DR; felbamate (PA required); gabapentin; lacosamide; lamotrigine/ER; levetiracetam/ER; oxcarbazepine; phenobarbital; phenytoin; pregabalin; primidone; tiagabine (PA required); topiramate/ER; valproic acid/valproate; zonisamide
Vimpat (lacosamide) - generic	Insufficient response or intolerance to at least TWO of: carbamazepine/ER; divalproex sodium ER/DR; felbamate (PA required); gabapentin; lamotrigine/ER; levetiracetam/ER; oxcarbazepine; phenobarbital; phenytoin; pregabalin; primidone; tiagabine (PA required); topiramate/ER; valproic acid/valproate; zonisamide
Vimpat (lacosamide) - brand	Documentation that generic lacosamide was insufficient AND insufficient response or intolerance to at least TWO of the agents listed for generic
Zarontin (ethosuximide) - generic/brand	Provider has submitted documentation that generic ethosuximide was insufficient (age-specific requirement applies for absence seizures)
Zonegran (zonisamide) - generic/brand	Provider has submitted documentation that generic zonisamide was insufficient (age-specific requirement applies)

Requirement	Notes / Special PA
Provider must document prior agents tried and failed	For many products the PA form requires listing each prior agent tried and failed; prior therapies will be verified via submitted documentation or pharmacy claims
Some listed agents require separate prior authorization	Felbamate and tiagabine are noted on multiple agent lists as requiring a separate PA — providers must indicate when these agents were tried and may need to submit additional justification due to safety/age restrictions (felbamate)
Brand product requests often require prior generic failure	Brand-specific criteria commonly require documentation that the corresponding generic formulation was insufficient before brand approval (examples: Aptiom, Briviact, Banzel, Fycompa, Felbatol, Keppra/Keppra XR, Lamictal, Vimpat, Oxtellar XR/Trileptal)
Document age/diagnosis-specific requirements when applicable	Many agents include minimum age and indication requirements that must be met and documented on the PA (e.g., Aptiom >=4 years; Briviact >=1 month; Banzel >=1 year for LGS; Oxtellar XR >=6 years; Vimpat age thresholds)
List all tried and failed agents on the PA form	PA form includes checkboxes for each acceptable prior agent — providers should check all that apply and include chart notes or other evidence of insufficient response or intolerance

Quantity Limits and Exceeding FDA/Labeling

Any listed anticonvulsant — quantity limits and evidence requirement

Quantity limit ruleRequested quantity must not exceed approved doses in FDA/package labeling, nationally recognized compendia, or peer‑reviewed literature; if it does, submit clinical trial data/literature supporting safety of the requested dose.

ScopeApplies to any listed anticonvulsant on the PA form (brands and generics).

Evidence requirementSubmission must include clinical trial data or literature demonstrating safety for doses above labeled/compendia limits.

Documentation consequenceAuthorization may be delayed or denied if supporting documentation (lab results, diagnostics, chart notes) is not provided.

Definitions and Clinical Indications

Clinical indications referenced (examples)

Partial‑onset seizuresReferenced as a covered indication for multiple agents (e.g., Aptiom: member ≥4 years; Keppra: ≥1 month; Lamictal: listed), and appears throughout drug‑specific criteria.

Lennox‑Gastaut syndrome (LGS)Specifically cited as an indication for rufinamide (Banzel), clobazam (Onfi), lamotrigine (Lamictal), and topiramate for LGS-related seizures.

Juvenile myoclonic epilepsy (JME) / myoclonic seizuresListed for levetiracetam (Keppra) where member ≥12 years with myoclonic seizures due to JME is an approval criterion.

Bipolar disorderLamotrigine (Lamictal) includes maintenance treatment of bipolar I disorder as a referenced indication (with limitations of use).

Background and Scope

This prior authorization form applies to outpatient anticonvulsant medications used to treat seizure disorders and related indications such as bipolar disorder, migraine prophylaxis, and neuropathic pain. All requests must meet the form's clinical criteria and include required documentation (diagnosis, dosing, prior therapy history, weight if applicable, and supporting labs/notes). The PA covers a broad list of anticonvulsants (see form) and emphasizes that all criteria must be met for approval and incomplete documentation may result in delay or denial.

Revision History and Approvals

This policy and the associated PA form have been reviewed and approved by the Pharmacy & Therapeutics Committee on multiple dates (historical approvals listed on the form). The document notes P&T approval entries including but not limited to 2/16/2012 and an entry indicating approval on 7/24/2025, with additional committee review dates recorded through 6/17/2022. Providers should reference the form for current Plan‑specific coverage and any updates tied to P&T review.

OpenPayer

Anticonvulsant Pharmacy Prior Authorization / Step-Edit Request (Outpatient Anticonvulsants)