ModifiedCignaPolicy N/A

Antiseizure Medications - Xcopri Drug Quantity Management Policy Per Rx

Defines drug quantity limits and medically necessary exceptions for Xcopri (cenobamate tablets) per dispensing at retail and home delivery for Cigna-administered benefit plans. Specifies approvals/dose consolidation rules and exception criteria by strength and dosage form.

Policy Summary

PayerCigna

PolicyAntiseizure Medications - Xcopri Drug Quantity Management Policy Per Rx

Policy CodePolicy N/A

Change TypeQuantity limits and exception criteria added/updated

Effective Date

Next Review Date

Key ActionIf the drug quantity management rule is not met at point of service, coverage will be determined by the documented exception criteria; approvals (when criteria met) are for 1 year.

SourceLink

POLICY UPDATE CHANGES

New quantity limit of 30 tablets per dispensing at retail and 90 tablets per dispensing at home delivery added for Xcopri 25 mg tablets.

Criteria added to approve larger quantities for 25 mg tablets when dose does not correspond to a commercially available dosage form (up to 450 retail / 1,350 home delivery).

Criteria added to approve larger quantities for 50 mg tablets when dose does not correspond to a commercially available dosage form (up to 210 retail / 630 home delivery).

Criteria added to approve 60 tablets retail or 180 tablets home delivery for 150 mg tablets when patient is taking a daily dose of 300 mg.

Criteria added to approve 60 tablets retail or 180 tablets home delivery for 200 mg tablets when patient is taking a daily dose of 400 mg.

Policy history notes review dates and that an Annual Revision added default limits for 25 mg tablets.

5Strengths with default limits listed

Strengths with medically necessary quantity exceptions added (25 mg, 50 mg)

2Strengths with daily dose-based approvals (150 mg, 200 mg)

Coverage Summary

Defines drug quantity limits and medically necessary exceptions for Xcopri (cenobamate) tablets per dispensing at retail and home delivery for Cigna-administered benefit plans. If the Drug Quantity Management rule is not met at point of service, coverage will be determined by the documented exception criteria. All approvals (when criteria are met) are provided for 1 year in duration.

Per‑Rx quantity thresholds (Xcopri)

Retail maximum per Rx (typical)30 tablets per strength

Home Delivery maximum per Rx (typical)90 tablets per strength

25 mg exception limitsApprove up to 450 tablets per dispensing at retail or 1,350 tablets per dispensing at home delivery when dose does not correspond to a commercially‑available dosage form

50 mg exception limitsApprove up to 210 tablets per dispensing at retail or 630 tablets per dispensing at home delivery when dose does not correspond to a commercially‑available dosage form

150 mg daily‑dose approvalIf patient is taking a daily dose of 300 mg, approve 60 tablets retail or 180 tablets home delivery

200 mg daily‑dose approvalIf patient is taking a daily dose of 400 mg, approve 60 tablets retail or 180 tablets home delivery

General Policy Statement

Drug Quantity Management rule and general approval duration:

Drug Quantity Management program promotes dose consolidation, prevents stockpiling and waste, and addresses potential order entry errors of Xcopri.

If the Drug Quantity Management rule is not met at point of service, coverage will be determined by the Criteria below.

All approvals are provided for 1 year in duration.

Quantity Limits by Strength / Form

Quantity Limits by Strength/Form

Default retail and home delivery maximum quantities per prescription:

25 mg tablets: Retail maximum quantity per Rx = 30 tablets; Home Delivery maximum quantity per Rx = 90 tablets.Retail=30;Home=90

50 mg tablets: Retail maximum quantity per Rx = 30 tablets; Home Delivery maximum quantity per Rx = 90 tablets.Retail=30;Home=90

100 mg tablets: Retail maximum quantity per Rx = 30 tablets; Home Delivery maximum quantity per Rx = 90 tablets.Retail=30;Home=90

Exceptions to Quantity Limits (Medically Necessary)

Exceptions are covered as medically necessary when listed criteria are met; any other exception is not medically necessary.

Provider Actions & Prior Authorization

Prior Authorization

Quantity limit enforcement and exceptions

If the Drug Quantity Management rule is not met at point of service, coverage will be determined by the documented exception criteria. When criteria are met, approvals are provided for 1 year in duration.

Documentation Required

Document dosing that does not match commercial strengths

For requests to approve larger quantities for 25 mg or 50 mg tablets, document that the patient's required dose does not correspond to a commercially-available dosage form (i.e., the dose requires multiple same-strength tablets or would otherwise require two or more strengths).

Applicable Codes

Drug (NDC not provided)NDC

No codes listed

Background & Definitions

Xcopri is indicated for the treatment of partial-onset seizures in adults and is administered once daily with a recommended titration schedule to a maintenance dose. Xcopri is available in multiple tablet strengths (25 mg, 50 mg, 100 mg, 150 mg, 200 mg) supplied in bottles of 30 tablets and in 28-day titration blister packs (12.5 mg/25 mg, 50 mg/100 mg, 150 mg/200 mg) and maintenance blister packs (250 mg/day and 350 mg/day). The Drug Quantity Management program aims to promote dose consolidation, prevent stockpiling and waste, and address potential order entry errors for Xcopri.

Definitions

Evidence (Prescribing Information)

Revision History

05/08/2024review

Annual revision added a new default quantity limit for Xcopri 25 mg tablets: 30 tablets per dispensing at retail and 90 tablets per dispensing at home delivery; no clinical overrides apply for this limit.

05/02/2025review

Annual review noted with no clinical criteria changes.

02/18/2026reviewLatest

Early annual revision added exception criteria permitting approval of larger quantities when the patient's dose does not correspond to a commercially-available dosage form: for 25 mg tablets approve up to 450 tablets retail / 1,350 home delivery (is_material: true); for 50 mg tablets approve up to 210 tablets retail / 630 home delivery (is_material: true). Also added daily-dose based approvals: for 150 mg tablets when patient is taking 300 mg/day approve 60 retail / 180 home delivery (is_material: true); for 200 mg tablets when patient is taking 400 mg/day approve 60 retail / 180 home delivery (is_material: true).

Policy Summary

PayerCigna

PolicyAntiseizure Medications - Xcopri Drug Quantity Management Policy Per Rx

Policy CodePolicy N/A

Change TypeQuantity limits and exception criteria added/updated

Effective Date

Next Review Date

Key ActionIf the drug quantity management rule is not met at point of service, coverage will be determined by the documented exception criteria; approvals (when criteria met) are for 1 year.

SourceLink

On This Page

150 mg tablets: Retail maximum quantity per Rx = 30 tablets; Home Delivery maximum quantity per Rx = 90 tablets.Retail=30;Home=90

200 mg tablets: Retail maximum quantity per Rx = 30 tablets; Home Delivery maximum quantity per Rx = 90 tablets.Retail=30;Home=90

Titration blister packs: Retail/Home Delivery maximum quantity per Rx = (not specified in policy).

12.5 mg/25 mg titration blister pack: Retail maximum per Rx = 28 tablets; Home Delivery = 28 tablets (contains 14 tablets of each strength).Retail=28;Home=28

50 mg/100 mg titration blister pack: Retail maximum per Rx = 28 tablets; Home Delivery = 28 tablets (contains 14 tablets of each strength).Retail=28;Home=28

150 mg/200 mg titration blister pack: Retail maximum per Rx = 28 tablets; Home Delivery = 28 tablets (contains 14 tablets of each strength).Retail=28;Home=28

Maintenance blister pack 250 mg/day: Retail maximum per Rx = 56 tablets; Home Delivery = 168 tablets (contains 28 x 100 mg and 28 x 150 mg tablets).Retail=56;Home=168

Maintenance blister pack 350 mg/day: Retail maximum per Rx = 56 tablets; Home Delivery = 168 tablets (contains 28 x 150 mg and 28 x 200 mg tablets).Retail=56;Home=168

Quick reference — default maxima

Default Retail maximum30 tablets per Rx

Default Home Delivery maximum90 tablets per Rx

Approval durationAll approvals provided for 1 year

Billing Rule

Use most appropriate codes when billing

Claims for services submitted without covered code(s) under the applicable coverage policy will be denied as not covered. Providers must use the most appropriate codes as of the effective date of submission when billing.