ModifiedPremera BluecrossPolicy N/A

Pharmacologic Treatment of Seizures (Antiseizure Medications)

This pharmacy policy defines when specific brand and formulation anti-seizure medications are considered medically necessary and the authorization limits for members receiving Premera Blue Cross coverage.

Policy Summary

PayerPremera Bluecross

PolicyPharmacologic Treatment of Seizures (Antiseizure Medications)

Policy CodePolicy N/A

Change TypeQuantity limits addedgeneric brivaracetam includedproduct removals

Effective DateJun 1, 2026

Next Review DateMay 25, 2026

Key ActionSubmit medical records including office visit notes, diagnosis, relevant history, physical evaluation, and medication history to support prior authorization and re-authorization requests.

SourceLink

POLICY UPDATE CHANGES

Added quantity limits per 30 days for Motpoly XR (lacosamide extended-release) and Sympazan (clobazam).

Updated criteria for Briviact (brivaracetam) adding the quantity is limited to 60 tablets or 600 ml per 30 days and Elepsia XR (levetiracetam extended-release) quantity limited to 60 tablets per 30 days.

Added generic brivaracetam to the policy with the same criteria as Briviact (brivaracetam).

Removed coverage criteria for certain products no longer on the market (e.g., Vigpoder, Qudexy XR) and removed discontinued products (Peganone/ethotoin).

~40+listed products

12 moinitial auth length (max)

up to 3 yrreauthorization

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

dose limitsdose limits present

50/100kepilepsy incidence

Coverage Criteria for Antiseizure Medications

Brand carbamazepine 200 mg chewable tablet

Brand carbamazepine 200 mg chewable tablet — ALL required criteria for medical necessity

ALL of the following

The individual has tried and had an inadequate response or intolerance to generic carbamazepine chewable tablet.
The individual has tried and had an inadequate response or intolerance to at least 1 additional generic anti-seizure medication.
The dose is limited to 1,600 mg per day.

Coding and Quantity Limits

Codingneutral

No codes listed

CPT/HCPCS/ICD-10mixed

No codes listed

Quantity limits (examples)

Briviact (brivaracetam)Quantity limited to 60 tablets or 600 mL per 30 days.

Elepsia XR (levetiracetam XR)Quantity limited to 60 tablets per 30 days.

Motpoly XR (lacosamide XR)Quantity limits added per 30 days (see product-level criteria for exact amounts).

Sympazan (clobazam)Quantity limits added per 30 days (see product-level criteria for exact amounts).

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization and Approval Length

Prior authorization is required for many drugs in this policy. Initial authorizations may be approved for up to 12 months for non‑formulary exception reviews and for specified specialty agents where noted. Re‑authorization may be approved for up to 3 years when drug‑specific coverage criteria are met and chart notes document continued positive clinical response to therapy.

Initial authorization: up to 12 months for non‑formulary exception reviews or as noted for specific agents
Re‑authorization: may be approved up to 3 years when criteria and documentation requirements are met

Step Therapy

Failure to Meet Trial or Dose Criteria / Formulation and Generic Trial Requirements

Many brand or specialty formulations require documented trials of specified generic formulations (generic‑first trial) or other step‑therapy trials before a brand product will be approved. Requests that do not show the required prior trials or that exceed dose limits may be denied.

Required trial of listed generic formulation(s) prior to brand approval where specified

Key Definitions and Epidemiology

Seizure / Epilepsy definitions

SeizureAn episode of abnormal, excessive or synchronous neuronal electrical activity in the brain; may be generalized or focal and can cause transient changes in movement, behavior, or consciousness.

EpilepsyA condition characterized by two or more unprovoked seizures >24 hours apart, a single seizure with a >60% risk of recurrence within 10 years, or an identified epilepsy syndrome.

Seizure typesIncludes focal (partial), generalized, and unknown onset seizures; focal seizures can be subdivided by level of awareness and motor vs non-motor dominant symptoms.

Epilepsy definition (diagnostic criteria)

Diagnostic criteria for epilepsyTwo or more unprovoked seizures >24 hours apart; or a single unprovoked seizure if the risk of recurrence is >60% within 10 years; or diagnosis of an epilepsy syndrome.

Classification basis

Clinical Background

Seizures are episodes of abnormal electrical activity in the brain; epilepsy denotes a condition of recurrent seizures. Choice of anti‑seizure medication depends on seizure type (focal versus generalized), patient age, comorbidities, and formulation needs (for example, difficulty swallowing may justify an orally disintegrating tablet or suspension). Management options include pharmacologic therapy as outlined in this policy, as well as dietary, surgical, and device‑based approaches where appropriate. The policy specifies when particular brand and formulation antiseizure medications are considered medically necessary and documents requirements such as trials of generic formulations, dose and quantity limits, and prior authorization processes.

Policy Revision History

2026-06-01Interim review / policy updateLatest

Updated criteria for Briviact (brivaracetam) to add a quantity limit of 60 tablets or 600 mL per 30 days; updated Elepsia XR (levetiracetam XR) criteria to add a quantity limit of 60 tablets per 30 days; added generic brivaracetam to the policy with the same criteria as Briviact.

2025-09-01Operational update

Clarified age indication for lacosamide (Motpoly XR) to include patients from 1 month and older; removed Peganone (ethotoin) as discontinued and removed Zonisamide oral suspension (product unavailability) while retaining Zonisade; interim review approved July 8, 2025 updated Aptiom criteria to require trial of generic eslicarbazepine first.

Policy Summary

PayerPremera Bluecross

PolicyPharmacologic Treatment of Seizures (Antiseizure Medications)

Policy CodePolicy N/A

Change TypeQuantity limits addedgeneric brivaracetam includedproduct removals

Effective DateJun 1, 2026

Next Review DateMay 25, 2026

Key ActionSubmit medical records including office visit notes, diagnosis, relevant history, physical evaluation, and medication history to support prior authorization and re-authorization requests.

SourceLink

On This Page

Step‑therapy: documentation of inadequate response or intolerance to required generics or alternative agents

Dose limits: approvals are subject to product‑specific maximum daily doses; exceeding these may result in denial

Denial Risk

Product Availability

Coverage may be denied if the product is discontinued, no longer marketed, or otherwise unavailable. When a product is removed from the market, refer to current policy history and formulary alternatives.

Product discontinued or not commercially available may not be covered
Check policy history for removed or replaced products

Note

Member Benefit Verification

Verify member coverage and benefit applicability before submitting a request. Member contracts differ; consult the member benefit booklet or contact member services to confirm pharmacy benefit coverage, prior authorization requirements, and any applicable limits or exclusions.

Drugs in this policy are managed under the pharmacy benefit
Contact member services or review the member benefit booklet for plan‑specific limits

Documentation Required

Required Documentation

Submit complete medical records with the prior authorization request. If required documentation (office visit notes, diagnosis, relevant history, physical exam, medication history) is not provided, the request may be delayed or denied.

Include office visit notes with diagnosis, relevant history, physical evaluation, and medication history
Chart notes must demonstrate continued clinical response for re‑authorization requests

The ILAE classification is based on seizure onset (type), epilepsy type, and syndrome (if present).

Implications for managementSeizure type and epilepsy classification guide treatment selection (e.g., drug choice, diet, surgery, devices).

Dravet syndrome

IncidenceDravet syndrome incidence approximately 1 per 22,000 births.

Typical onsetSeizures typically begin at approximately 6 months of age; development and EEGs often normal until 1–2 years of age.

Genetic associationAbout 80%–85% of patients have heterozygous loss-of-function mutations in SCN1A (sodium channel α-1 subunit).

CDKL5 deficiency disorder (CDD)

Core disorder descriptionCDKL5 deficiency disorder (CDD) is caused by non-functional CDKL5 protein and presents with early-onset epileptic seizures, epileptic encephalopathy, and severe psychomotor developmental impairment.

Typical onset and courseSeizures start within the first three months of life and most often do not respond to pharmacological treatment; encephalopathy and developmental delay are observed early.

Incidence and demographicsCDD incidence approximately 1 in 40,000–60,000 newborns; about 90% of diagnosed cases are female due to CDKL5 being X-linked.

Dravet syndrome — additional notes

Clinical characterizationDravet syndrome is a severe developmental and epileptic encephalopathy with prolonged febrile seizures in infancy, progression to multiple seizure types, and poor cognitive and behavioral outcomes.

Mortality and complicationsPremature mortality reported (~21%); common causes include SUDEP and status epilepticus; mean age of death reported as 8.7 years in referenced data.

Therapeutic contextFenfluramine (Fintepla) has been evaluated specifically for treatment-resistant seizures in Dravet syndrome in randomized trials and reviews.

2025-03-01New policy

New policy approved February 11, 2025 and added multiple seizure drugs to the Prescription Drug section including Aptiom, Briviact, Diacomit, Epidiolex, Fintepla, Fycompa, Libervant, Motpoly XR, Oxtellar XR, Peganone, Qudexy XR, Sabril, Spritam, and Sympazan.