By Counterforce Health Team in Keppra (levetiracetam) —

Do You Qualify for Keppra (Levetiracetam) Coverage by Humana in North Carolina? Decision Tree & Next Steps

Answer Box: Your Path to Keppra Coverage

Generic levetiracetam is typically covered by Humana without prior authorization for FDA-approved seizure disorders. Brand Keppra requires documented failure of generic. If denied, you have 65 days to appeal internally, then can request North Carolina's Smart NC external review within 120 days. First step today: Call the number on your Humana ID card to verify formulary status and request a coverage determination if needed.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible": Document Checklist
  4. If "Possibly Eligible": Tests and Timeline
  5. If "Not Yet": Alternatives and Exceptions
  6. If Denied: Appeal Path Chooser
  7. Decision Flowchart
  8. Humana Coverage Requirements
  9. North Carolina External Review Process
  10. FAQ: Common Questions
  11. Resources and Contact Information

How to Use This Decision Tree

This guide helps patients and clinicians navigate Humana's coverage requirements for Keppra (levetiracetam) in North Carolina. Work through the eligibility questions below, then follow the recommended path based on your situation.

Important: This applies to North Carolina residents with Humana commercial plans. Medicare Advantage members follow different federal appeal rules, not Smart NC external review.

Eligibility Triage: Do You Qualify?

Step 1: Confirm Your Diagnosis

Does your diagnosis include epilepsy or seizure disorder?

✅ Yes, I have documented:

  • Partial-onset (focal) seizures
  • Myoclonic seizures in juvenile myoclonic epilepsy
  • Primary generalized tonic-clonic seizures
  • Other epilepsy diagnosis with ICD-10 code

❌ No or unsure → Request neurologist consultation and EEG if not done

Step 2: Check Prior Therapy Requirements

For generic levetiracetam: Usually no prior authorization needed

For brand Keppra, have you:

  • Tried generic levetiracetam for ≥4 weeks at therapeutic dose?
  • Documented inadequate seizure control OR intolerable side effects?
  • Have medical records showing the trial and failure?

✅ Yes to all → Likely eligible for brand coverage ⚠️ Partially → Possibly eligible, may need additional documentation ❌ No → Must complete generic trial first (unless contraindicated)

Step 3: Verify Plan Type

What type of Humana plan do you have?

  • Commercial/employer plan → Use this guide + Smart NC if needed
  • Medicare Advantage → Follow federal Medicare appeals, not Smart NC
  • Self-funded/ERISA plan → Limited Smart NC access, check with HR

If "Likely Eligible": Document Checklist

You meet basic criteria. Gather these documents before submitting:

Required Documentation

Document Type What to Include Where to Get It
Insurance Info Humana ID card, member number, group number Your wallet/portal
Diagnosis ICD-10 codes, seizure type classification Neurologist notes
EEG Results Epileptiform activity, seizure patterns Hospital/clinic records
Prior Therapy Names, dates, doses, outcomes of failed meds Pharmacy records, chart notes
Current Status Seizure frequency, impact on daily life Seizure diary, clinic visit notes

Submission Path

  1. Call Humana (number on ID card) to initiate coverage determination
  2. Provider submits medical necessity letter with documentation
  3. Track timeline: 72 hours for standard, 24 hours if expedited
  4. If denied: File appeal within 65 days

If "Possibly Eligible": Tests and Timeline

You may qualify but need additional documentation. Here's what to pursue:

Missing Pieces to Address

If no recent EEG: Request from neurologist to confirm epileptiform activity If incomplete trial history: Gather pharmacy records showing dates and doses If no specialist involvement: Consider neurology referral for complex cases If unclear seizure classification: Ask for detailed seizure semiology documentation

Timeline to Re-Apply

  • Gather missing records: 1-2 weeks
  • Schedule specialist visit: 2-4 weeks
  • Complete additional testing: 1-3 weeks
  • Resubmit request: Submit as soon as documentation is complete
Tip: Use Humana's transition policy for temporary 30-day fills while gathering documentation if you're new to the plan.

If "Not Yet": Alternatives and Exceptions

You don't currently meet standard criteria. Consider these options:

Covered Alternatives to Discuss

  • Generic levetiracetam (if requesting brand Keppra)
  • Other first-line antiseizure medications per Humana's formulary
  • Different dosing schedules within quantity limits

Exception Request Strategy

Medical contraindication: Document allergy or intolerance to covered options Unique clinical factors: Highlight pregnancy, drug interactions, or comorbidities Specialist recommendation: Include neurologist/epileptologist support letter

Prepare for Future Approval

  1. Start seizure diary to track baseline frequency
  2. Trial covered alternatives with careful documentation
  3. Schedule regular follow-ups to monitor response
  4. Maintain detailed records of all medication trials

If Denied: Appeal Path Chooser

Level 1: Humana Internal Appeal

Timeline: 65 days from denial notice Method: Humana appeals portal or written request Required: Original denial letter, additional medical documentation Decision time: 7 days standard, 72 hours expedited

Level 2: Smart NC External Review (Commercial Plans Only)

Eligibility: North Carolina residents with fully-insured Humana commercial plans Timeline: 120 days from final Humana denial Process: Submit Smart NC external review form Cost: Free to patient Decision: Binding on Humana if approved

Note: Medicare Advantage plans use federal Independent Review Entity (IRE), not Smart NC.

When to Request Expedited Review

  • Life-threatening situation: Uncontrolled seizures with injury risk
  • Status epilepticus history: Previous episodes requiring emergency care
  • Functional decline: Loss of driving, employment, or independence
  • Pregnancy: Seizure control critical for maternal/fetal safety

Decision Flowchart

Start: Need Keppra Coverage
│
├─ Generic levetiracetam? → Usually approved → Submit standard PA
│
├─ Brand Keppra needed?
│  │
│  ├─ Generic trial completed? 
│  │  ├─ Yes → Document failure → Submit brand PA
│  │  └─ No → Complete 4-week trial first
│  │
│  └─ Contraindication to generic?
│     ├─ Yes → Document allergy/intolerance → Submit exception
│     └─ No → Complete trial requirement
│
└─ If denied at any step:
   │
   ├─ Commercial plan → Humana appeal → Smart NC external review
   │
   └─ Medicare Advantage → Humana appeal → Federal IRE review

Humana Coverage Requirements

Generic Levetiracetam

  • Prior authorization: Usually not required
  • Formulary tier: Typically Tier 1 (lowest copay)
  • Quantity limits: Standard dosing ranges covered
  • Medical necessity: FDA-approved seizure indications

Brand Keppra

  • Prior authorization: Required in most plans
  • Step therapy: Must try generic first
  • Documentation needed:
    • 4+ week generic trial at therapeutic dose
    • Objective evidence of failure (seizure logs)
    • OR documented intolerance/allergy

Exception Criteria

Per Humana's formulary exception process:

  • All covered alternatives would be less effective
  • Covered alternatives would cause adverse effects
  • Utilization restrictions are clinically inappropriate

North Carolina External Review Process

Smart NC Eligibility

  • Fully-insured commercial Humana plans (not self-funded/ERISA)
  • Final denial from Humana internal appeals
  • Medical necessity dispute (not just coverage preferences)
  • 120-day deadline from final denial letter

How to Request

  1. Download form from NC Department of Insurance
  2. Complete sections: Patient info, Humana plan details, denied medication, medical necessity rationale
  3. Attach documents: Denial letters, medical records, prescriber letter
  4. Submit to Smart NC: Mail, fax, or secure upload per form instructions

What Happens Next

  • Smart NC review: 10 business days to determine eligibility
  • IRO assignment: Independent clinical experts review case
  • Decision timeline: 45 days standard, 72 hours expedited
  • Binding result: Humana must comply if overturned

Smart NC Support

Call 1-855-408-1212 for free help with:

  • Determining plan eligibility
  • Completing external review forms
  • Gathering supporting documentation
  • Understanding the process timeline

FAQ: Common Questions

How long does Humana prior authorization take in North Carolina? Standard requests: 72 hours. Expedited requests: 24 hours. Appeals: 7 days standard, 72 hours expedited.

What if Keppra is non-formulary on my plan? Request a formulary exception with medical necessity documentation. If denied, appeal through Smart NC external review.

Can I get temporary coverage while my appeal is pending? New members may qualify for 30-day transition fills. Ask Humana about continuation coverage during appeals.

Does step therapy apply if I failed medications outside North Carolina? Yes, document all prior trials regardless of location. Include pharmacy records and provider notes from previous states.

What's the difference between Humana appeals and Smart NC review? Humana appeals are internal company decisions. Smart NC uses independent medical experts and is binding on Humana if approved.

How do I know if my plan qualifies for Smart NC? Commercial/employer plans usually qualify. Medicare Advantage and self-funded plans typically don't. Call Smart NC at 1-855-408-1212 to verify.

Resources and Contact Information

Humana Contacts

North Carolina Resources

Clinical Support

  • FDA Keppra Label: FDA Access Data
  • Epilepsy Foundation: Local North Carolina chapters for patient advocacy
  • Neurology Specialists: For complex cases requiring specialist documentation

Need personalized help navigating insurance appeals? Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals that align with payer requirements, helping patients, clinicians, and specialty pharmacies get prescription drugs approved more efficiently.

This guide provides general information about insurance coverage and appeals processes. It is not medical advice. Consult your healthcare provider for medical decisions and contact Humana or Smart NC directly for plan-specific guidance. Coverage policies and procedures may change; verify current requirements with official sources.

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