By Counterforce Health Team in Keppra (levetiracetam) —

How to Get Keppra (Levetiracetam) Covered by Aetna CVS Health in Michigan: Complete Prior Authorization Guide

Answer Box: Fast Track to Coverage

Getting Keppra (levetiracetam) covered by Aetna CVS Health in Michigan typically requires prior authorization if requesting brand Keppra, as most plans prefer generic levetiracetam. Your fastest path: Start with generic levetiracetam (usually Tier 1-2, minimal barriers). If brand Keppra is medically necessary, submit electronic PA via Caremark's ePA portal with documented generic failure/intolerance. Michigan requires 15-day response (72 hours if expedited). If denied, you have 127 days to file external review with Michigan DIFS. First step today: Check your formulary tier and confirm PA requirements by calling Aetna member services.

Table of Contents

Before You Start: Coverage Basics

Verify Your Plan Type and Coverage

First, confirm whether your Aetna plan is subject to Michigan state regulations. Self-funded employer plans may have different appeal rights. Call the member services number on your insurance card to verify.

Understanding Keppra vs. Generic Levetiracetam Coverage

Generic levetiracetam is typically covered on Tier 1 or 2 with lower copays and minimal restrictions. Brand Keppra and Keppra XR, however, are often non-formulary or placed on high tiers, requiring:

  • Prior authorization
  • Step therapy (trial of generic first)
  • Medical necessity documentation
Important Note: UCB discontinued marketing branded Keppra/Keppra XR in the U.S., so most prescriptions will be for generic levetiracetam, which has fewer coverage barriers.

Check Your Formulary Status

Log into your Aetna member portal or call member services to confirm:

  • Whether levetiracetam requires prior authorization
  • Your specific formulary tier and copay
  • Any quantity limits or step therapy requirements

What You Need to Gather

Essential Documentation

Medical Information:

  • Diagnosis with ICD-10 codes (e.g., G40.9 for epilepsy, unspecified)
  • Complete seizure history and frequency
  • Previous antiepileptic drugs tried, doses, duration, and outcomes
  • Documentation of side effects or contraindications to other medications
  • Current medication list and dosing rationale

Clinical Records:

  • Recent progress notes from your neurologist or epileptologist
  • EEG results, brain imaging if relevant
  • Lab results showing drug levels or monitoring parameters
  • Hospital records if seizure-related admissions occurred

Insurance Documents:

  • Insurance card and policy information
  • Any previous denial letters
  • Prior authorization forms (Michigan requires electronic submission when possible)

Michigan-Specific Requirements

As of June 1, 2023, Michigan requires electronic prior authorization (ePA) submission via Caremark's portal. Paper or fax submissions are only accepted with documented technical failures and proper certification using Form FIS 2288.

Submitting Your Prior Authorization Request

Electronic Submission (Preferred Method)

  1. Access the Portal: Your prescriber should use Caremark's ePA system
  2. Complete Required Fields: Include all clinical documentation and medical necessity justification
  3. Submit Supporting Documents: Attach clinical notes, lab results, and prior therapy records
  4. Obtain Confirmation: Keep the submission confirmation number for tracking

Alternative Submission (Technical Failures Only)

If electronic submission is unavailable due to technical issues:

  1. Complete Form FIS 2288 with technical failure certification
  2. Fax to appropriate number:
    • Non-specialty medications: 1-888-836-0730
    • Specialty medications: 1-866-249-6155
  3. Include all required documentation as with electronic submission

What Makes a Strong Request

Medical Necessity Letter Should Include:

  • Clear diagnosis and seizure classification
  • Specific reasons why levetiracetam is appropriate (e.g., broad-spectrum coverage, minimal drug interactions)
  • Documentation of previous treatment failures or contraindications
  • Dosing rationale based on weight, age, or renal function
  • Treatment goals and expected outcomes

Following Up on Your Request

When to Call

  • Day 7: If no acknowledgment received
  • Day 12: If approaching the 15-day deadline
  • Immediately: If you submitted an expedited request and haven't heard back within 72 hours

Contact Information

  • Aetna Prior Authorization Department: 1-800-294-5979 (Monday–Friday, 8am–6pm CST)
  • CVS Caremark Provider Services: Contact through their provider portal

What to Ask

  • "What's the status of PA request [reference number]?"
  • "What additional information is needed?"
  • "When can I expect a decision?"
  • "Can this be expedited due to medical urgency?"

Understanding Timelines

Request Type Insurer Response Time Auto-Approval if No Response
Standard PA 15 days Yes
Expedited PA 72 hours Yes
Additional Info Requested Same timeline after receipt N/A

What Affects Processing Speed

Faster Processing:

  • Complete initial submission with all required documents
  • Electronic submission via ePA
  • Clear medical necessity justification
  • Standard formulary medications

Slower Processing:

  • Missing clinical documentation
  • Non-formulary or brand requests requiring additional review
  • Requests requiring peer-to-peer review
  • Fax submissions (when permitted)

If More Information is Requested

Respond Promptly

You have limited time to provide additional information:

  • Standard requests: 21 days
  • Expedited requests: 5 days

Failure to respond within these timeframes voids your request.

Common Additional Information Requests

  • More detailed clinical notes
  • Specific lab values or drug levels
  • Documentation of contraindications to preferred alternatives
  • Peer-to-peer discussion with the medical director

If Your Request is Denied

Understanding Denial Reasons

Common reasons for levetiracetam denials:

  • Request for brand when generic is available and not contraindicated
  • Insufficient documentation of medical necessity
  • Failure to try preferred formulary alternatives first
  • Dosing outside typical parameters without justification

Immediate Next Steps

  1. Review the denial letter carefully for specific reasons
  2. Gather additional supporting documentation to address cited concerns
  3. Consider peer-to-peer review if clinical judgment is questioned
  4. File internal appeal within Aetna's required timeframe

Appeals Process in Michigan

Internal Appeals with Aetna

Timeline: Typically 30-60 days for standard appeals, 72 hours for urgent appeals How to File: Through your Aetna member portal, by phone, or written request What to Include: Original denial letter, additional clinical evidence, updated medical necessity letter

External Review with Michigan DIFS

If Aetna upholds their denial, you have 127 days from the final denial date to request external review.

How to File:

Required Documents:

  • Aetna's final denial letter
  • Your insurance policy information
  • Medical records supporting necessity
  • Physician letter of medical necessity

Timeline:

  • Standard review: Up to 60 days
  • Expedited review: 72 hours (requires physician certification of urgency)

Outcome: The external review decision is binding on Aetna

From our advocates: We've seen Michigan external reviews frequently overturn denials when patients provide comprehensive clinical documentation showing clear medical necessity. The key is demonstrating that the requested medication is the most appropriate choice for the specific clinical situation, not just that it's an acceptable option.

Renewal and Re-authorization

When to Start the Process

  • 60 days before your current authorization expires
  • Immediately if your clinical situation changes
  • After any formulary updates that might affect coverage

What to Include for Renewals

  • Updated clinical notes showing continued medical necessity
  • Current seizure control status
  • Any new contraindications to alternative therapies
  • Documentation of continued efficacy

Common Denial Reasons & Solutions

Denial Reason Solution
"Generic available" Document specific medical necessity for brand (allergies to inactive ingredients, bioequivalence concerns with breakthrough seizures)
"Not medically necessary" Provide detailed clinical rationale, seizure history, and treatment goals
"Step therapy required" Document previous trials of preferred alternatives with specific reasons for failure/intolerance
"Quantity limits exceeded" Justify higher dosing based on clinical factors (weight, renal function, seizure control)

Frequently Asked Questions

Q: How long does Aetna CVS Health prior authorization take in Michigan? A: Standard requests must receive a response within 15 days under Michigan law. Expedited requests require a response within 72 hours. If Aetna doesn't respond within these timeframes, the request is automatically approved.

Q: What if levetiracetam is non-formulary on my plan? A: You can request a formulary exception by demonstrating medical necessity. This requires comprehensive clinical documentation showing why formulary alternatives are inappropriate for your specific situation.

Q: Can I request an expedited prior authorization? A: Yes, if your physician certifies that waiting for a standard review would jeopardize your health. This is common for patients with poorly controlled seizures or those switching from another antiepileptic drug.

Q: Does step therapy apply if I was stable on levetiracetam in another state? A: Document your previous successful treatment and any clinical reasons why switching to a preferred alternative would be inappropriate. Continuity of care arguments can be compelling.

Q: What if I can't afford the copay even with approval? A: Look into manufacturer patient assistance programs, state pharmaceutical assistance programs, and foundation grants. Generic levetiracetam is also available at reduced cost through various pharmacy discount programs.

Quick Reference Checklist

Before Submitting:

  • Verify PA requirement and formulary tier
  • Gather complete medical records and clinical notes
  • Obtain ICD-10 diagnosis codes
  • Document previous treatment trials and outcomes
  • Prepare medical necessity justification

Submission:

  • Use electronic ePA when possible
  • Include all required clinical documentation
  • Obtain confirmation number
  • Calendar follow-up dates

If Denied:

  • Review denial letter for specific reasons
  • Gather additional supporting evidence
  • File internal appeal promptly
  • Consider peer-to-peer review
  • Know your external review rights (127 days in Michigan)

Getting prescription coverage approved doesn't have to be overwhelming. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies, then drafts point-by-point rebuttals with the right clinical evidence and procedural requirements for your specific payer and state.

Whether you're navigating Aetna's prior authorization process or facing a denial, having the right documentation and understanding your appeal rights in Michigan can make the difference between coverage and paying out of pocket. Remember that Counterforce Health specializes in creating compelling appeals that address payer-specific requirements while tracking deadlines and procedural details.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. Coverage policies and procedures may change; verify current requirements with your insurer and state regulators.

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