Health Net
Xcopri (250 MG Daily Dose) (cenobamate)
Drugs for the Nervous System : Drugs for Seizures /Personality Disorder/Nerve Pain
  • Neurology: Epilepsy:
    Age Requirement: >= 18
    Duration: 1 plan year
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Neurologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 plan year
    Diagnosis Type(s): Partial-Onset Seizures
    Used as Adjunctive Treatment: No
    Duration of Failure or Adjunctive Treatment with Other Antiepileptic Product: N/A
    Documented history of persisting seizures after titration to highest tolerated dose of each AED.: No
    Lack of compliance as a reason for treatment failure has been ruled out: No
    Documentation of treatment failure due to intolerable side effects.: No
    Supporting Documentation Requirements: Chart Notes
    Positive Response to Therapy Required for Reauth: No
    Treatment for Age 17 years or older: Yes
    Treatment for Age 1-16 years old: No
    History of >= to 30 day trial of other AED required: No
    Reapproval based on response: No

  • Prior Authorization: Neurology: Epilepsy:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 1 plan year
    Reauthorization Required: Yes

  • Step Therapy: Neurology: Epilepsy:
    ST Multiple Generics