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 bypassesapproval duration revisedappendix 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.

SourceLink

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/day

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