CurrentmhnPolicy CP.PMN.156
Perampanel (Fycompa) prior authorization / medical necessity
Defines medical necessity criteria, age limits, step-therapy exceptions, dosing limits, approval durations, and documentation requirements for Fycompa (perampanel) for commercial, HIM and Medicaid lines of business.
Policy Summary
Payermhn
PolicyPerampanel (Fycompa) prior authorization / medical necessity
Policy CodePolicy CP.PMN.156
Change TypeStep therapy bypasses; approval duration revised; appendix updates
Effective DateNov 16, 2016
Next Review Date
Key ActionProvider must submit documentation (office chart notes, lab results or other clinical information) supporting that member meets approval criteria; PA is required for initial and renewal requests.
POLICY UPDATE CHANGES
Added step therapy bypass for Illinois HIM per IL HB 5395 (effective 1/1/2026)
Revised approval duration for Commercial to 12 months or duration of request, whichever is less
Added redirection bypass for members in states with limitations on step therapy and Appendix D
3Q 2025 annual review: no significant changes; references reviewed and updated
2FDA Approved Indications
4-12 mgCommon dosing range
12 mg/dayMaximum dose limit