CurrentCignaPolicy N/A

Antiseizure Medications - Lacosamide Step Therapy Policy

Defines step therapy requirements for coverage of lacosamide products (generic lacosamide, Vimpat, Motpoly XR) under Cigna-administered health benefit plans; affects prescribers and prior authorization reviewers.

Policy Summary

PayerCigna

PolicyAntiseizure Medications - Lacosamide Step Therapy Policy

Policy CodePolicy N/A

Change TypeAdded Motpoly XRadministrative name change

Effective DateN/A

Next Review Date03/12/2025

Key ActionTry one Step 1 product (generic lacosamide) before submitting for approval of a Step 2 product; approvals are granted for 1 year when criteria are met.

SourceLink

POLICY UPDATE CHANGES

Motpoly XR added to Step 2 products.

Policy name changed from 'Antiepileptics - Lacosamide Step Therapy' to 'Antiseizure Medications - Lacosamide Step Therapy Policy'.

1 yearapproval duration

Step 1 → Step 2sequencing

≥1 molacosamide min age

≥4 yrsadjunctive therapy age

Coverage Criteria

Initial therapy (Step 1 then Step 2)

Covered when ALL of the following are met

Step therapy requirement: Patient has tried one Step 1 product (generic lacosamide tablets or generic lacosamide oral solution).1 product tried

If met, approve Step 2 product for 1 year

Any use of the listed Step 2 lacosamide products that does not meet the step therapy requirements is considered not medically necessary. The policy requires adherence to the step sequence described below; exceptions are only as specified in the criteria. Coverage determinations follow the step therapy criteria and approvals are provided for 1 year when criteria are met.

Use of a Step 2 product (Motpoly XR or Vimpat formulations) without first trying at least one Step 1 product (generic lacosamide tablets or generic lacosamide oral solution) is considered not medically necessary unless the step therapy criteria are otherwise met. The program is designed to encourage use of a Step 1 product prior to Step 2 therapy.

Provider Actions & Prior Authorization

Policy Summary

PayerCigna

PolicyAntiseizure Medications - Lacosamide Step Therapy Policy

Policy CodePolicy N/A

Change TypeAdded Motpoly XRadministrative name change

Effective DateN/A

Next Review Date03/12/2025

Key ActionTry one Step 1 product (generic lacosamide) before submitting for approval of a Step 2 product; approvals are granted for 1 year when criteria are met.

SourceLink

On This Page

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Step Therapy

Step Therapy Overview

If the Step Therapy rule is not met for a Step 2 product at the point of service, coverage will be determined by the Step Therapy criteria below. All approvals are provided for 1 year in duration.

Step 1: generic lacosamide tablets, generic lacosamide oral solution
Step 2: Motpoly XR, Vimpat tablets, Vimpat oral solution

Prior Authorization

Prior Authorization Requirement

Approval for a Step 2 product is provided for 1 year when the patient has tried one Step 1 product; otherwise coverage is determined by the Step Therapy rules and may be denied if the step sequence is not met at point of service.

If the patient has tried one Step 1 product, approve a Step 2 product.
Coverage for Step 2 products will be denied if the Step Therapy rule is not met at point of service.

Note

Decision Factors

Coverage determinations require consideration of the applicable benefit plan, relevant laws and regulations, and collateral source materials. Each request should be reviewed on its own merits and medical directors may exercise clinical judgment.

Requirement	Coverage determination
Patient has trialed one Step 1 product (generic lacosamide tablets or generic lacosamide oral solution).	Status: Covered — approve a Step 2 product (Motpoly XR, Vimpat tablets, or Vimpat oral solution) for 1 year.

Definitions & Indications

Lacosamide indications

Indication — partial-onset seizuresTreatment of partial-onset seizures in patients ≥ 1 month of age.

Indication — primary generalized tonic‑clonic seizures (adjunctive)Adjunctive therapy in the treatment of primary generalized tonic‑clonic seizures in patients ≥ 4 years of age.

Drug examplesIncludes branded Vimpat and generic lacosamide formulations (tablets and oral solution).

Age considerationsMinimum age 1 month for partial‑onset seizure indication; minimum age 4 years for adjunctive primary generalized tonic‑clonic seizure indication.

Motpoly XR indications

Indication — partial-onset seizuresTreatment of partial‑onset seizures in adults and in pediatric patients weighing ≥ 50 kg.

Indication — primary generalized tonic‑clonic seizures (adjunctive)Adjunctive therapy in the treatment of primary generalized tonic‑clonic seizures in adults and in pediatric patients weighing ≥ 50 kg.

Weight restrictionPediatric use limited to patients weighing ≥ 50 kg.

ProductMotpoly XR (lacosamide extended‑release capsules).

OpenPayer

Antiseizure Medications - Lacosamide Step Therapy Policy

Coverage Criteria

Provider Actions & Prior Authorization

Initial Therapy

Step Therapy Table

Definitions & Indications

Background