Coverage Policies

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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 10/01/2020 Title: Xcopri (cenobamate)
Revision Date: Document: BI665:00
CPT Code(s): N/A
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Xcopri (cenobamate) requires prior authorization.

2)    Xcopri is used to treat a type of seizure in adults.

3)    Xcopri is covered under the pharmacy benefit.


Medical Statement

Xcopri is considered medically necessary in members who meet all the following criteria:

1)    Diagnosis of partial-onset seizures;

2)    Age > 18 years;

3)    Failure of at least two generic anticonvulsants indicated for partial seizures, unless contraindicated or clinically significant adverse effects are experienced;

4)    Dose does not exceed 400mg per day.

Initial authorization is for 12 months.

 

Reauthorization (12 months) is allowed if documentation provided that member is responding positively to therapy.


Reference

1)    Xcopri Prescribing Information. Paramus, NJ: SK Life Science, Inc.; November 2019.

2)    Clinical Pharmacology. Accessed online 08-11-20.

3)    Krauss GL, Klein P, Brandt C, et al. Safety and efficacy of adjunctive cenobamate (YKP3089) in patients with uncontrolled focal seizures: a multicenter, double-blind, randomized, placebo-controlled, dose-response trial. Lancet Neurology 2019; published online November 13, 2019.


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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