By Counterforce Health Team in Keppra (levetiracetam) —

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

Answer Box: Getting Keppra Covered by Aetna CVS Health in Pennsylvania

Most Aetna CVS Health plans in Pennsylvania cover generic levetiracetam without prior authorization for FDA-approved seizure disorders. Brand-name Keppra typically requires step therapy (trying generic first) or medical necessity documentation. If denied, you have strong appeal rights through Pennsylvania's new external review program, which overturns about 50% of denials.

Your fastest path to approval:

  1. Check if generic levetiracetam meets your needs (often covered without PA)
  2. If brand Keppra is required, have your doctor document medical necessity for the brand
  3. If denied, appeal within 180 days using Pennsylvania's external review process

Take action today: Call the number on your member ID card to verify your specific plan's requirements.

Table of Contents

Policy Overview: Aetna CVS Health Plans in Pennsylvania

Aetna CVS Health operates several plan types in Pennsylvania, each with different formulary rules for Keppra (levetiracetam):

  • Commercial plans (employer-sponsored): Usually cover generic levetiracetam without prior authorization
  • Marketplace/ACA plans: Similar coverage to commercial, available through Pennie (Pennsylvania's marketplace)
  • Medicare Advantage: May have different formulary tiers and quantity limits
  • Medicaid (Aetna Better Health): Often requires prior authorization for brand medications

Where to Find Your Specific Coverage Rules

Your exact coverage depends on your specific plan design. Key resources include:

  • Member portal: Log in at aetna.com to check your formulary
  • Precertification lists: Available in Aetna's 2024 PA requirements
  • Plan documents: Your Summary of Benefits and Coverage (SBC) outlines specific drug coverage rules

Coverage Requirements for Keppra vs Generic Levetiracetam

Medication Typical Coverage Status Prior Authorization Required? Common Copay Tier
Generic levetiracetam Preferred/Standard formulary Usually no Tier 1-2 ($10-40)
Brand Keppra Non-preferred or not covered Yes, with step therapy Tier 3-4 ($50-150+)
Keppra XR Non-preferred or not covered Yes, with step therapy Tier 3-4 ($50-150+)
Note: Brand-name Keppra and Keppra XR are no longer actively marketed by UCB in the U.S., but some pharmacies may still stock them. Most prescriptions are automatically filled with generic levetiracetam.

FDA-Approved Indications for Levetiracetam

Levetiracetam is FDA-approved for:

  • Partial-onset seizures: Ages 1 month and older (monotherapy and adjunctive)
  • Myoclonic seizures: Ages 12 and older with juvenile myoclonic epilepsy (adjunctive)
  • Primary generalized tonic-clonic seizures: Ages 6 and older with idiopathic generalized epilepsy (adjunctive)

Coverage is typically straightforward for these FDA-approved uses when prescribed by a neurologist or epilepsy specialist.

Step Therapy and Medical Necessity Exceptions

Aetna CVS Health requires step therapy for brand Keppra: patients must try generic levetiracetam first before the brand version is covered.

Medical Necessity Override Documentation

To bypass step therapy and get brand Keppra covered, your prescriber must document:

Required clinical evidence:

  • Specific medical reason generic levetiracetam failed or is inappropriate
  • Documentation of adverse reactions, allergies, or lack of therapeutic effect
  • Clinical notes showing different generic manufacturers tried (if applicable)
  • Treating provider's rationale for preferring brand Keppra

Common acceptable reasons for brand preference:

  • Documented intolerance to inactive ingredients in generic formulations
  • Breakthrough seizures when switched from brand to generic
  • Absorption issues requiring consistent bioavailability of brand product
  • Patient stability concerns during generic manufacturer switches

How to Request a Medical Exception

  1. Prescriber initiates: Only your doctor can submit the request
  2. Use Aetna's PA process: Submit through provider portal or by fax
  3. Include comprehensive documentation: Clinical history, failed trials, rationale
  4. Request expedited review if urgent: Can reduce processing time to 24-72 hours

Prior Authorization Process and Timeline

Standard Prior Authorization Steps

  1. Prescriber submits PA request via:
    • CVS Caremark provider portal (preferred)
    • Fax to number on member ID card
    • Phone: 1-800-294-5979 (provider line)
  2. Required documentation includes:
    • Patient demographics and insurance information
    • Diagnosis with ICD-10 codes
    • Clinical justification for brand Keppra
    • Documentation of generic trial failures
    • Prescribing provider's medical rationale
  3. Review timeline:
    • Standard review: 30-45 days for commercial plans
    • Expedited review: 24-72 hours if medically urgent
    • Medicare plans: 72 hours for expedited, 14 days for standard

When Prior Authorization May Not Be Required

Good news: Aetna's 2024 precertification lists show that generic levetiracetam typically doesn't require prior authorization for standard FDA-approved indications in Pennsylvania.

Appeals Process: Internal and External Review

If your Keppra request is denied, Pennsylvania offers one of the strongest patient appeal systems in the country.

Internal Appeals (First Step)

Timeline: Must appeal within 180 days of denial Process:

  1. Call member services number on your ID card
  2. Request written appeal form or submit online
  3. Include prescriber's letter supporting medical necessity
  4. Aetna has 30 days to respond (15 days for urgent requests)

Pennsylvania External Review (Second Step)

Pennsylvania launched its own Independent External Review Program in January 2024, with impressive results for patients.

Key statistics: In 2024, Pennsylvania's external review program processed 4,815 cases, with approximately 50% of appealed denials overturned in favor of patients.

How it works:

  1. Exhaust internal appeals first: Get your "Final Adverse Benefit Determination" letter
  2. File within 4 months: Submit external review request to Pennsylvania Insurance Department
  3. Independent review: Third-party physicians review your case
  4. Binding decision: If overturned, Aetna must cover the medication immediately

Submit your external review:

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn Required Documentation
"Generic available" Medical necessity for brand Prescriber letter documenting generic failure/intolerance
"Not FDA-approved for condition" On-label use confirmation FDA prescribing information, diagnosis codes
"Quantity exceeds limits" Dosing justification Weight-based calculations, seizure frequency records
"Step therapy not completed" Exception request Documentation of contraindications to required steps
"Experimental/investigational" Established use evidence Published guidelines, FDA approval status

Scripts for Common Situations

Patient calling Aetna member services:

"I'm calling about a denial for my Keppra prescription. My doctor says I need the brand version because I had breakthrough seizures on the generic. I'd like to request a medical necessity exception and understand the appeal process."

Prescriber requesting peer-to-peer review:

"I'm requesting a peer-to-peer review for my patient who needs brand Keppra due to documented breakthrough seizures when switched to generic levetiracetam. The patient has epilepsy and requires consistent bioavailability for seizure control."

Pennsylvania External Review Success Stories

Pennsylvania's new external review program has shown strong results for patients fighting medication denials. In the program's first year, the Pennsylvania Insurance Department reported that independent review organizations ruled in favor of patients in approximately 259 out of 517 cases—a roughly 50% success rate.

What this means for Keppra denials: If your internal appeal is unsuccessful, Pennsylvania's external review gives you a genuine second chance with independent medical experts reviewing your case.

Why external reviews succeed: Independent physicians often have different perspectives than insurance company reviewers and may be more willing to approve medications when clinical documentation clearly supports medical necessity.

When Counterforce Health helps patients navigate these appeals, we've seen that thorough documentation of failed generic trials and clear clinical rationale significantly improve approval odds. The platform helps identify the specific denial basis and creates targeted appeals that align with both Aetna's policies and Pennsylvania's patient protection standards.

Clinician Corner: Medical Necessity Documentation

Medical Necessity Letter Checklist for Brand Keppra

Essential elements to include:

✅ Patient identification: Name, DOB, member ID, diagnosis with ICD-10 codes ✅ Clinical problem: Specific seizure type, frequency, impact on daily function ✅ Prior treatments: Generic levetiracetam trials, dates, outcomes, reasons for failure ✅ Medical rationale: Why brand Keppra is necessary (bioavailability, stability, etc.) ✅ Supporting evidence: FDA prescribing information, epilepsy guidelines if applicable ✅ Dosing justification: Weight-based calculations, therapeutic monitoring results ✅ Monitoring plan: How you'll assess effectiveness and safety

Key Clinical References

  • FDA prescribing information: Keppra label (FDA Access Data)
  • Clinical evidence: StatPearls levetiracetam review provides evidence-based summary
  • Dosing guidelines: FDA-approved dosing by age and indication in prescribing information
From our advocates: We've seen that letters mentioning "breakthrough seizures when switched from brand to generic" combined with specific dates and seizure frequency data tend to get approved more quickly than general statements about "patient doing well on brand." Include concrete clinical details whenever possible.

Cost-Saving Options and Patient Assistance

If Your Appeal is Unsuccessful

Manufacturer assistance: While UCB no longer markets brand Keppra in the U.S., generic manufacturers may offer patient assistance programs Pharmacy shopping: Generic levetiracetam prices vary significantly—GoodRx shows some pharmacies offer 60 tablets for under $20 State programs: Pennsylvania has pharmaceutical assistance programs for eligible residents

Foundation Grants and Support

  • Epilepsy Foundation: Offers medication assistance programs
  • Patient advocate organizations: Can help navigate appeals and find financial assistance
  • Specialty pharmacies: CVS Specialty may offer payment plans for covered medications

For complex appeals involving rare seizure types or off-label uses, platforms like Counterforce Health can help generate evidence-backed appeals that align with payer policies and improve approval odds.

FAQ: Keppra Coverage Questions

Q: How long does Aetna CVS Health prior authorization take in Pennsylvania? A: Standard reviews take 30-45 days for commercial plans, but expedited reviews can be completed in 24-72 hours if medically urgent.

Q: What if Keppra is completely non-formulary on my plan? A: Request a formulary exception with medical necessity documentation. If denied, use Pennsylvania's external review process, which has a 50% success rate.

Q: Can I request an expedited appeal for my seizure medication? A: Yes, seizure medications often qualify for expedited review due to the urgent nature of epilepsy treatment. Request this specifically when filing your appeal.

Q: Does step therapy apply if I was stable on brand Keppra before switching to Aetna? A: You can request a step therapy exception based on prior successful treatment, but you'll need documentation from your previous prescriber showing stability on the brand product.

Q: What happens if Pennsylvania's external review approves my Keppra? A: Aetna must provide coverage immediately, including retroactive coverage if you paid out-of-pocket during the appeal process.

Q: Can my neurologist request a peer-to-peer review with Aetna's medical director? A: Yes, peer-to-peer reviews are available and can be effective for complex cases where clinical nuance matters.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by individual plan. Always consult with your healthcare provider about treatment decisions and verify current coverage requirements with your insurance company. For personalized help with complex appeals, consider consulting with patient advocacy services or platforms like Counterforce Health that specialize in insurance appeals for prescription medications.

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