By Counterforce Health Team in Keppra (levetiracetam) —

How to Get Keppra (Levetiracetam) Covered by Blue Cross Blue Shield in Washington: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Keppra Covered in Washington

Blue Cross Blue Shield plans in Washington typically cover generic levetiracetam on formulary, but brand-name Keppra may require prior authorization. The fastest path to approval: (1) Check your specific plan's formulary using their online tool, (2) If denied, submit a medical necessity exception with documented generic failure or intolerance, (3) Use Washington's external review process if internal appeals fail. Start by calling the member services number on your insurance card to confirm current requirements.

Table of Contents

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization May be required for brand Keppra; generics typically covered Plan formulary or member portal Regence WA Formulary
Formulary Tier Generic levetiracetam on preferred tiers; brand on higher tiers Online drug lookup tool Premera Formulary
Step Therapy Must try generics first before brand approval Plan policy documents Plan-specific
Medical Necessity Required for brand-over-generic requests Exception request forms Plan-specific
Appeals Deadline 180 days from denial for internal appeals Washington state law WA Insurance Commissioner

Step-by-Step: Fastest Path to Approval

1. Verify Current Coverage Status

Who does it: Patient or caregiver
What you need: Insurance card, member portal login
Timeline: 5-10 minutes online

Check your specific Blue Cross Blue Shield plan's formulary using their online tool. For Regence BlueShield, visit regence.com. For Premera Blue Cross, use their drug lookup tool.

2. Contact Member Services

Who does it: Patient or authorized representative
What you need: Member ID, medication details
Timeline: 10-15 minute phone call

Call the number on your insurance card to confirm prior authorization requirements, formulary tier, and any step therapy protocols for your specific plan and medication formulation.

3. Gather Clinical Documentation

Who does it: Healthcare provider and patient
What you need: Medical records, seizure logs, prior medication history
Timeline: 1-3 business days

Collect comprehensive documentation including:

  • Epilepsy/seizure disorder diagnosis with ICD-10 codes
  • Previous antiepileptic drug trials and outcomes
  • Seizure frequency logs
  • Any adverse reactions to generic formulations
  • Current medication regimen and response

4. Submit Prior Authorization Request

Who does it: Prescribing physician
What you need: PA form, clinical documentation, prescription
Timeline: Submit within 24-48 hours of prescription

Your doctor submits the prior authorization through your plan's provider portal or fax system. Include all supporting clinical documentation and clear medical necessity justification.

5. Monitor Decision Timeline

Who does it: Patient and provider office
What you need: Reference number from submission
Timeline: 7-14 business days for standard review

Track your request status through the member portal or by calling member services. For urgent situations, request expedited review (72-hour decision timeline).

6. Appeal if Denied

Who does it: Patient with provider support
What you need: Denial letter, additional clinical evidence
Timeline: Must appeal within 180 days of denial

If denied, immediately begin the internal appeal process while gathering additional supporting documentation.

7. Request External Review if Needed

Who does it: Patient
What you need: Final internal denial letter, all appeal documentation
Timeline: Request within 180 days of final internal denial

Contact the Washington State Office of the Insurance Commissioner at 800-562-6900 for external review assistance.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Generic available Prove medical necessity for brand Generic failure/intolerance records, seizure logs showing breakthrough seizures
Step therapy not completed Document prior medication trials Pharmacy records, clinical notes showing previous ASM failures
Not medically necessary Strengthen clinical justification Specialist letter, seizure disorder severity documentation, treatment goals
Quantity limits exceeded Justify higher dose/frequency Weight-based dosing calculations, therapeutic drug monitoring results
Off-label use Provide evidence-based support Medical literature, specialty guidelines, FDA labeling for similar indications

Appeals Playbook for Blue Cross Blue Shield in Washington

Internal Appeals Process

Level 1: Standard Internal Appeal

  • Timeline: Must file within 180 days of denial
  • Decision timeframe: 30 days (15 days for urgent)
  • How to file: Written request to address on denial letter or through member portal
  • Required: Denial letter, additional clinical documentation, member statement

Level 2: Second Internal Review (if available)

  • Timeline: 180 days from Level 1 denial
  • Decision timeframe: 30 days
  • How to file: Follow plan-specific procedures
  • Required: Previous appeal documentation plus new evidence

External Review Process

Independent Review Organization (IRO)

  • Eligibility: After completing internal appeals or if plan fails to respond timely
  • Timeline: Request within 180 days of final internal denial
  • Decision timeframe: 20 days (72 hours for expedited)
  • How to request: Contact Washington Insurance Commissioner at 800-562-6900
  • Binding: Yes, decision is final and binding on the insurer
Tip: Washington's external review process has strong consumer protections. The IRO can overturn the plan's definition of "medical necessity" if it's unreasonably restrictive.

Medical Necessity Letter Template

When requesting brand-name Keppra over generic levetiracetam, your neurologist should include these key elements:

Patient Information & Diagnosis

  • Full name, DOB, insurance ID
  • Specific epilepsy diagnosis with ICD-10 codes
  • Seizure type and frequency
  • Duration of epilepsy history

Prior Treatment History

  • Detailed list of previous antiepileptic medications tried
  • Duration of each trial and reasons for discontinuation
  • Specific adverse effects or lack of efficacy with generics
  • Documentation of breakthrough seizures on generic formulations

Clinical Rationale for Brand Keppra

  • Medical necessity for brand over generic
  • Risk of seizure breakthrough with generic substitution
  • Patient stability on current brand formulation
  • Narrow therapeutic index considerations

Supporting Evidence

  • Seizure logs showing control on brand vs. generic
  • Pharmacy records documenting generic trials
  • Any hospitalization or ER visits related to seizure breakthrough
  • Therapeutic drug monitoring results if available

When to Escalate: Washington External Review

Washington state provides robust consumer protections for insurance denials. Contact the Office of the Insurance Commissioner if:

  • Your internal appeals are denied
  • The insurer fails to respond within required timeframes
  • You believe the denial violates state insurance laws
  • You need help navigating the appeals process

Washington Office of the Insurance Commissioner

  • Phone: 800-562-6900
  • Website: insurance.wa.gov
  • External Review: Available after internal appeals are exhausted
  • Consumer Advocacy: Free assistance with appeals and complaints

The external review process in Washington is particularly effective because independent medical experts review your case, and their decision is binding on the insurer.

Costs & Savings Options

Even with insurance coverage, Keppra costs can vary significantly:

Generic Levetiracetam Pricing

  • Typical retail: $20-40 for 60 tablets of 500mg
  • With insurance: Varies by formulary tier and copay structure
  • Pharmacy shopping: Prices vary significantly between pharmacies

Patient Assistance Options

  • GoodRx: Discount coupons for uninsured or high-deductible plans
  • Manufacturer programs: Check UCB's patient assistance programs
  • State programs: Washington Apple Health (Medicaid) for eligible patients
  • Pharmacy discount programs: Many chains offer generic medication discounts
From our advocates: One Washington patient successfully appealed a Keppra XR denial by documenting that generic immediate-release formulations caused breakthrough seizures due to dosing frequency challenges. The key was detailed seizure logs showing the correlation between formulation changes and seizure patterns, plus a strong neurologist letter emphasizing medication adherence issues with multiple daily dosing.

FAQ

How long does Blue Cross Blue Shield prior authorization take in Washington? Standard prior authorization decisions are made within 7-14 business days. Expedited reviews for urgent situations must be completed within 72 hours.

What if Keppra is not on my formulary? You can request a formulary exception through your plan's coverage determination process. This requires documentation that covered alternatives are not appropriate for your condition.

Can I request an expedited appeal if my seizures are not controlled? Yes. If delayed access to medication could seriously jeopardize your health, you can request expedited review at both the internal appeal and external review levels.

Does step therapy apply if I failed medications in another state? Documentation from out-of-state providers is generally accepted, but you may need to provide detailed records showing the medication trials and outcomes.

What's the difference between Regence and Premera coverage in Washington? Both are Blue Cross Blue Shield licensees but have separate formularies and prior authorization criteria. Check your specific plan's requirements using their online tools.

How much does external review cost in Washington? External review through the Insurance Commissioner's office is free to consumers. The insurer pays the IRO review fee.

Can my doctor request a peer-to-peer review? Yes, most Blue Cross Blue Shield plans offer peer-to-peer reviews where your prescribing physician can discuss the case directly with the plan's medical director.

What happens if I'm switching from brand to generic due to cost? Work closely with your neurologist to monitor for breakthrough seizures. Some patients require dose adjustments when switching formulations.

Getting the right coverage for seizure medications shouldn't add stress to managing epilepsy. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform ingests denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned to each plan's specific requirements, pulling the right medical evidence and citations to support your case.

For additional support with complex appeals or if you're facing repeated denials, consider working with advocates who specialize in insurance coverage for neurological medications. The combination of Washington's strong consumer protections and proper documentation often leads to successful outcomes, even for initially denied claims.

Sources & Further Reading

This guide provides educational information about insurance coverage and appeals processes. It is not medical advice. Always consult with your healthcare provider about treatment decisions and work with your insurance plan's member services for plan-specific requirements. Coverage policies and procedures may change; verify current information with official sources.

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