CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Medicaid_Xcopri_20250115 1

Policy governing Medicaid coverage and authorization criteria for Xcopri (cenobamate) for treatment of partial onset seizures, including initial and continuation criteria, quantity limits, and coverage duration.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedicaid_Xcopri_20250115 1

Policy CodePolicy N/A

Change TypeReviewed (no material change)

Effective DateOct 1, 2020

Next Review Date

Key ActionObtain authorization demonstrating all initial approval criteria: age ≥18, neurologist prescriber or consultation, diagnosis of partial onset seizures, exclusion of Familial Short QT syndrome, counseling on DRESS risk, documentation of seizure frequency, and documentation of trial/failure of ≥2 AEDs.

SourceLink

POLICY UPDATE CHANGES

Reviewed dates listed through 1/2025; no clinical policy statement changes indicated in document.

1Covered Indication

12 moCoverage Duration

>=2Required prior AED trials

Coverage Summary

Policy governing Medicaid coverage and authorization criteria for Xcopri (cenobamate) for partial onset seizures. Coverage stance: covered_with_criteria. Status: CURRENT. Effective date: 2020-10-01. Last review: 2025-01-01. This policy applies to Medicaid members and references the manufacturer package insert (October 2023).

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Initial Therapy Criteria

Initial Approval

An authorization may be granted when all the following criteria are met:

ALL of the following

The patient is at least 18 years of age
The prescriber is a neurologist or prescribed in consultation with a neurologist
The patient does not have Familial Short QT syndrome
Prescriber is aware and counseled the patient on the potential for the side effect of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)/Multiorgan Hypersensitivity
The patient has a diagnosis of partial onset seizures
ONE OF
- Documentation that the patient has had a trial of at least 2 other antiepileptic drugs titrated to an appropriate maintenance dose
- Failure of at least two other antiepileptic drugs due to intolerable side effects
Documentation of seizure frequency

Provider Actions

Prior Authorization

Prior authorization required with initial criteria

Obtain prior authorization demonstrating all initial approval criteria listed below. Authorization requires evidence that the patient meets each initial criterion before coverage is approved.

Patient is at least 18 years of age
Prescriber is a neurologist or prescribed in consultation with a neurologist
Diagnosis of partial onset seizures
No history of Familial Short QT syndrome
Prescriber has counseled the patient about the potential for DRESS/multiorgan hypersensitivity
Documentation of a trial of at least 2 other antiepileptic drugs titrated to an appropriate maintenance dose or failure of at least two other antiepileptic drugs due to intolerable side effects
Documentation of baseline seizure frequency

Documentation Required

Document seizure frequency and response

Require documentation of the patient’s baseline seizure frequency at initiation of therapy. For continuation/renewal requests, require documentation showing a decrease in seizure frequency compared with baseline.

Billing Rule

Quantity limits by strength/pack

Adhere to the policy’s specified tablet-per-day limits and titration pack limits by product strength. Prescriptions must conform to the listed daily tablet limits and titration pack dosing as described in the policy.

Specific tablet-per-day limits and titration pack rules are detailed in the policy (see quantity limit section)

Term	Definition
DRESS
Partial onset seizures