By Counterforce Health Team in Keppra (levetiracetam) —

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

Answer Box: Quick Path to Keppra Coverage

Generic levetiracetam is typically covered by Aetna CVS Health in Ohio without prior authorization. Brand Keppra requires step therapy—you must try generic first unless medically necessary. If denied, you have 65 days to appeal and can request external review through Ohio's Department of Insurance within 180 days. First step today: Check your specific plan formulary at aetna.com or call member services to confirm coverage tier and requirements.

Table of Contents

  1. Coverage Basics: Is Keppra Covered?
  2. Prior Authorization Process
  3. Timeline and Urgency
  4. Step Therapy Requirements
  5. Cost Breakdown
  6. Denials and Appeals in Ohio
  7. External Review Rights
  8. Common Denial Reasons and Solutions
  9. Frequently Asked Questions
  10. Resources and Next Steps

Coverage Basics: Is Keppra Covered?

Generic levetiracetam is covered on most Aetna CVS Health formularies as a Tier 1 (preferred generic) medication. Brand Keppra faces more restrictions and may be excluded from some formularies in favor of the generic equivalent.

Coverage at a Glance

Medication Formulary Status Prior Auth Required Step Therapy Typical Copay
Levetiracetam (generic) Tier 1 Preferred Usually No Rarely $0-$15
Keppra (brand) Tier 3 or Excluded Usually Yes Yes $50+ or 20-50%
Note: Coverage varies by specific Aetna plan. Always verify with your plan's formulary or call member services at 1-866-235-5660.

Which Plans Cover Keppra?

Aetna CVS Health covers levetiracetam across their Ohio products:

  • Individual and family marketplace plans
  • Employer-sponsored group plans
  • Medicare Advantage plans
  • Medicaid managed care (Aetna Better Health)

The specific requirements and costs depend on your plan design and the version prescribed (generic vs. brand).

Prior Authorization Process

Good news: Most Aetna plans don't require prior authorization for generic levetiracetam when prescribed for FDA-approved seizure disorders. However, brand Keppra typically requires approval.

When Prior Authorization is Needed

  • Requesting brand Keppra instead of generic
  • High doses or non-standard formulations
  • Off-label uses (though seizure disorders are FDA-approved)
  • Specific plan restrictions (check your formulary)

Step-by-Step: Fastest Path to Approval

  1. Prescriber checks formulary via Aetna's provider portal
  2. Submit complete request including:
    • Patient demographics and diagnosis
    • Clinical justification for brand vs. generic (if applicable)
    • Documentation of seizure disorder with ICD-10 codes
    • Previous medication trials and outcomes
  3. Use preferred submission method:
    • Online via Availity provider portal (fastest)
    • Phone: 1-888-632-3862 (commercial) or 1-800-624-0756 (Medicare)
  4. Track status through provider portal or phone
  5. Receive decision within 72 hours (standard) or 24 hours (expedited)

Timeline and Urgency

Standard Processing Times

  • Prior authorization decision: 72 hours from complete submission
  • Appeal response: 7 days (72 hours) for standard appeals
  • Expedited appeals: 36-72 hours depending on urgency

When to Request Expedited Review

Call 1-866-235-5660 for expedited processing if:

  • Patient is experiencing breakthrough seizures
  • Current medication supply is running out
  • Delay would seriously jeopardize health

Your prescriber can also request expedited review by documenting medical urgency in the prior authorization request.

Step Therapy Requirements

Aetna typically requires step therapy for brand Keppra, meaning patients must try generic levetiracetam first. This policy aims to use the most cost-effective option while maintaining clinical effectiveness.

Medical Necessity Exceptions

Your doctor can request a step therapy override by documenting:

  • Adverse reactions to generic levetiracetam (rash, behavioral changes, breakthrough seizures)
  • Documented ineffectiveness of generic formulation
  • Specific formulation needs (e.g., liquid formulation not available as generic)
  • Bioequivalence concerns based on patient-specific factors

Required Documentation for Override

  • Clinical notes detailing adverse reactions or treatment failure
  • Seizure logs showing breakthrough activity on generic
  • Laboratory results if relevant
  • Previous medication trial history

Cost Breakdown

Understanding your out-of-pocket costs helps you plan for treatment expenses.

Typical Patient Costs in Ohio

Generic Levetiracetam (Tier 1):

  • Copay plans: $0-$15 per month
  • Coinsurance plans: 10-20% of negotiated rate
  • High-deductible plans: Full cost until deductible met

Brand Keppra (Tier 3 or non-formulary):

  • Copay plans: $50-$100+ per month
  • Coinsurance plans: 20-50% of negotiated rate
  • May require prior authorization even with higher cost-sharing

Money-Saving Options

  • Generic substitution: Ask your prescriber about generic levetiracetam
  • Manufacturer support: UCB offers patient assistance programs (verify current availability)
  • GoodRx or pharmacy discount programs: For uninsured portions
  • Ohio prescription assistance: Contact Ohio Department of Commerce for state programs

Denials and Appeals in Ohio

If Aetna denies your Keppra request, you have strong appeal rights under both federal and Ohio state law.

Appeals Playbook for Ohio Residents

Level 1: Internal Appeal

  • Deadline: 65 days from denial notice
  • Submit to: Aetna appeals address (verify current contact)
  • Response time: 7 days (standard) or 72 hours (expedited)
  • Required documents: Denial letter, medical records, prescriber statement

Level 2: External Review (Ohio)

  • Who handles it: Ohio Department of Insurance
  • Deadline: 180 days from final internal denial
  • Timeline: 30 days (standard) or 72 hours (expedited)
  • Decision: Binding on Aetna if overturned

How to File an Appeal

  1. Gather documents:
    • Original denial letter
    • Complete medical records
    • Prescriber's letter of medical necessity
    • Previous medication trial documentation
  2. Submit via multiple methods:
    • Online: www.aetnamedicare.com (Medicare plans)
    • Phone: 1-866-235-5660
    • Mail: Aetna Medicare Part D Appeals, PO Box 14579, Lexington, KY 40512
    • Fax: 1-724-741-4954
  3. Track your appeal through member portal or phone
From our advocates: We've seen many Keppra denials overturned when prescribers include specific details about breakthrough seizures on generic formulations and cite bioequivalence studies. The key is comprehensive documentation of why the generic isn't clinically appropriate for that specific patient.

External Review Rights

Ohio residents have particularly strong external review rights that can overturn Aetna denials.

Ohio's External Review Process

Who qualifies: Any Ohio resident with a state-regulated health plan (individual, small group, fully insured employer plans)

What's covered: Medical necessity denials, not contractual exclusions

How it works:

  1. File request with Aetna (who forwards to Ohio DOI)
  2. Independent Review Organization (IRO) assigned
  3. Medical experts review your case
  4. Decision is binding on Aetna

Getting Help in Ohio

  • Ohio Department of Insurance: 1-800-686-1526
  • Consumer Services Division: Assists with appeal questions
  • UHCAN Ohio: Nonprofit advocacy for coverage issues
  • OSHIIP: Medicare-specific assistance (for 65+ or disabled)

Contact the Ohio Department of Insurance if Aetna claims your case isn't eligible for external review—Ohio regulators can independently determine eligibility.

Common Denial Reasons and Solutions

Denial Reason How to Overturn Key Documents
"Generic available" Document medical necessity for brand Adverse reaction notes, seizure logs
"Not medically necessary" Provide FDA indication and guidelines Diagnosis codes, clinical guidelines
"Experimental/investigational" Cite FDA approval and standard of care FDA labeling, peer-reviewed studies
"Step therapy not completed" Request override with clinical justification Prior medication trial documentation
"Quantity limits exceeded" Justify higher dose with clinical rationale Dosing guidelines, patient weight/response

Clinician Corner: Medical Necessity Letter Checklist

When writing appeals for Keppra coverage, include:

✓ Specific diagnosis with ICD-10 codes (G40.x for epilepsy) ✓ FDA indication for levetiracetam in seizure disorders ✓ Previous treatments tried and failed (with dates and outcomes) ✓ Clinical rationale for brand vs. generic (if applicable) ✓ Seizure frequency and impact on daily functioning ✓ Monitoring plan and treatment goals ✓ Supporting literature from neurology guidelines

Frequently Asked Questions

How long does Aetna prior authorization take in Ohio? Standard decisions come within 72 hours of complete submission. Expedited requests are processed within 24 hours when medical urgency is documented.

What if Keppra is non-formulary on my plan? You can request a formulary exception by having your prescriber submit medical necessity documentation. The process is similar to prior authorization.

Can I request an expedited appeal? Yes, if a delay would seriously jeopardize your health. Call 1-866-235-5660 or have your prescriber mark the request as urgent.

Does step therapy apply if I've been stable on brand Keppra? Existing therapy is usually grandfathered, but check with your plan. New prescriptions typically face step therapy requirements.

What if my employer plan is self-funded? Self-funded ERISA plans follow federal rules, not Ohio's external review process. However, many voluntarily offer similar appeal rights.

How do I find my plan's specific formulary? Log into your member portal at aetna.com or request a copy from member services.

Resources and Next Steps

Immediate Action Items

  1. Check your formulary at Aetna's medication finder
  2. Contact member services at 1-866-235-5660 for coverage verification
  3. Work with your prescriber to gather necessary documentation
  4. Consider generic first unless medically contraindicated

Key Contacts

  • Aetna Member Services: 1-866-235-5660 (24/7)
  • Ohio Department of Insurance: 1-800-686-1526
  • CVS Caremark (pharmacy benefits): 1-888-407-6425
  • Provider appeals: 1-888-632-3862 (commercial)

Professional Support

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to create point-by-point rebuttals aligned with payer requirements, pulling the right citations and clinical evidence to maximize approval chances.

For complex cases or repeated denials, consider working with Counterforce Health to develop a comprehensive appeal strategy that addresses your specific plan's requirements and maximizes your chances of coverage approval.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal processes may change. Always verify current requirements with your specific plan and consult healthcare providers for medical decisions. For personalized assistance with Ohio insurance appeals, contact the Ohio Department of Insurance Consumer Services Division.

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