CurrentMass General Brigham Health PlanPolicy N/A

Anticonvulsant step therapy (Oxtellar XR, Eprontia, Trokendi XR)

Step-therapy, quantity limit, and prior authorization rules for selected oral anticonvulsant medications under the pharmacy benefit for Mass General Brigham Health Plan members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyAnticonvulsant step therapy (Oxtellar XR, Eprontia, Trokendi XR)

Policy CodePolicy N/A

Change TypeAdded drug and revised step therapy designations

Effective DateJun 1, 2022

Next Review DateN/A

Key ActionSubmit a prior authorization request at point of sale when the prescription does not meet initial step therapy requirements.

SourceLink

POLICY UPDATE CHANGES

Added new drug Eprontia as a second-line agent.

Updated step therapy criteria making generics first-line and designating Oxtellar XR & Trokendi XR as second-line.

Approvals will be granted for 36 months.

36 moapproval duration

3second-line branded

180lookback days

Coverage Criteria

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This policy defines step‑therapy requirements for selected oral anticonvulsant medications. First‑line agents listed in the Coverage Guidelines are covered without prior authorization. The branded agents Oxtellar XR, Trokendi XR, and Eprontia are designated second‑line and require meeting step‑therapy before adjudicating without prior authorization.

To meet step‑therapy for a second‑line agent, the member must have filled at least two first‑line medications OR have filled a second‑line medication within the past 180 days. If these criteria are not met, a prior authorization is required and prescriptions will deny at point of sale until approved.

When approved under these criteria, authorizations are issued for 36 months. Providers should submit a prior authorization request at the point of sale for members who do not meet the initial step‑therapy requirements.

Provider Actions & Prior Authorization

Prior Authorization

Prior authorization required

Prescriptions that meet the initial step therapy requirements will adjudicate automatically at the point of sale. If the prescription does not meet the initial step therapy requirements, the prescription will deny at point of sale with a message indicating that prior authorization (PA) is required. Submit a prior authorization request for members who do not meet the initial step therapy requirements at the point of sale.

Point-of-sale denials will include an instruction to submit PA
Submit PA for members who have not met initial step-therapy requirements

Step Therapy

Initial Step-Therapy Requirements

Initial step-therapy requirements: First-line medications listed below are covered without prior authorization. Second-line medications (including Oxtellar XR, Trokendi XR, and Eprontia) will only pay if the member has filled at least TWO first-line medications or a second-line medication within the past 180 days.

First-line agents are covered without PA (see Coverage Guidelines for full list)
Second-line agents (e.g., Oxtellar XR, Trokendi XR, Eprontia) require prior trials: ≥2 fills of first-line agents OR a filled second-line agent in the prior 180 days

Documentation Required

Prior authorization submission

For prescriptions that are denied at point of sale for not meeting step-therapy requirements, providers must submit a prior authorization request following the plan's PA process. Include documentation of prior medication trials, dates of fills, and clinical rationale for exceptions when applicable.

Include medication names, fill dates, and supporting clinical notes with the PA submission
Use PA submission channels specified by the plan (electronic portal or fax) at time of denial

Denial Risk

Point-of-sale denials for step therapy noncompliance

Prescriptions that do not meet the initial step therapy requirements will deny at the point of sale and require prior authorization before the claim will adjudicate. Expect a point-of-sale denial message directing you to submit PA.

Denial at point of sale indicates PA is required; do not resubmit claim without PA
If urgent clinical need, include that justification in the PA request to expedite review

Initial Therapy Designations

Initial therapy designations

First-line: Medications listed as first-line in the Coverage Guidelines are covered without prior authorization.

See Coverage Guidelines list for specific agents (e.g., carbamazepine, gabapentin, lamotrigine, levetiracetam, immediate‑release oxcarbazepine, topiramate immediate release, etc.).

Second-line: Oxtellar XR, Trokendi XR, and Eprontia are designated second-line and require meeting step-therapy (two prior first-line fills OR a prior second-line fill within 180 days) to adjudicate without prior authorization.180 days

Step	Requirement	Coverage
1
Member must have filled at least TWO first-line medications OR have filled a second-line medication within the past 180 days (lookback period = 180 days).
Second-line agents (Oxtellar XR, Trokendi XR, Eprontia) will pay only if step-therapy requirement met; otherwise prior authorization is required at point of sale.