By Counterforce Health Team in Keppra (levetiracetam) —

How to Get Keppra (Levetiracetam) Covered by Blue Cross Blue Shield Ohio: Cost-Saving Strategies and Appeal Guide

Answer Box: Getting Keppra Covered by BCBS Ohio

Levetiracetam (generic Keppra) is typically covered on Blue Cross Blue Shield Ohio formularies as a Tier 1-2 preferred generic with $0-$15 copays. Brand Keppra requires a formulary exception with medical necessity documentation. First step today: Log into your BCBS member portal to check your specific formulary tier and copay, then contact your prescriber if a brand exception is needed. Ohio residents have 180 days to file external appeals through the Ohio Department of Insurance if coverage is denied.

Table of Contents

  1. What Drives Your Keppra Costs
  2. Checking Your BCBS Ohio Coverage
  3. Cost-Saving Assistance Options
  4. Requesting Formulary Exceptions
  5. Retail vs. Mail-Order Pharmacy
  6. Appeals Process in Ohio
  7. Planning for Annual Changes
  8. Conversation Scripts
  9. FAQ

What Drives Your Keppra Costs

Your out-of-pocket cost for Keppra depends on several factors in your Blue Cross Blue Shield Ohio plan design:

Formulary Tier Placement Generic levetiracetam typically appears on BCBS Ohio formularies in low-cost tiers:

  • Tier 1 (Preferred Generic): $0-$10 copay for 30-day supply
  • Tier 2 (Generic): $5-$15 copay for 30-day supply
  • Higher tiers: Brand Keppra, if covered, may cost $30+ without an exception

Plan Type Variations Your specific BCBS Ohio plan affects coverage:

  • Commercial plans: Standard formulary tiers with predictable copays
  • Medicare Advantage: May have different tier structure and coverage gaps
  • High-deductible plans: You pay full price until deductible is met
Note: Anthem manages pharmacy benefits for BCBS Ohio, so your drug list may be labeled as "Anthem Enhanced" or similar.

Checking Your BCBS Ohio Coverage

Step 1: Access Your Formulary

  1. Log into your BCBS member portal or visit MyPrime.com (Anthem's pharmacy manager)
  2. Search for "levetiracetam" and "Keppra" to see tier placement
  3. Note any restrictions like quantity limits or prior authorization requirements

Step 2: Verify Your Specific Costs

Call the customer service number on your insurance card to confirm:

  • Your exact copay for generic levetiracetam
  • Whether brand Keppra is covered at all
  • Any step therapy requirements
  • Mail-order vs. retail pricing differences

Coverage at a Glance Table

Coverage Element Generic Levetiracetam Brand Keppra Where to Verify
Formulary Status Tier 1-2 (covered) May require exception Member portal drug lookup
Typical Copay $0-$15 (30-day) $30+ or not covered Insurance card or portal
Prior Authorization Usually not required Often required Call customer service
Quantity Limits Rarely applied May apply Formulary document
Step Therapy Not typically required May require generic trial Plan documents

Cost-Saving Assistance Options

Manufacturer Support

UCB Patient Assistance Program provides free Keppra for qualifying patients:

  • Eligibility: Uninsured or underinsured with demonstrated financial hardship
  • Income limits: Specific thresholds not publicly disclosed; screening required
  • Application: Call UCBCares at 844-599-CARE or visit UCB-USA.com Financial Assistance
  • Process: Prescriber completes application with income/insurance verification
Important: This is not a copay card program. It's designed for patients without adequate insurance coverage.

Ohio-Specific Resources

Epilepsy Alliance Ohio (EAO) offers the most comprehensive medication assistance in the state:

Emergency Assistance Fund:

  • Up to $3,000 annually for urgent epilepsy-related expenses
  • Covers one month of medication paid directly to pharmacy
  • Requires confirmed epilepsy diagnosis and financial hardship documentation
  • Contact: Epilepsy-Ohio.org

Pharmaceutical Patient Assistance Programs:

  • EAO helps patients apply for manufacturer programs
  • Income guidelines typically under $18,000 (individual) or $25,000 (family)
  • Medications mailed to prescriber or patient
  • Re-application required every 9-12 months

National Foundation Support

If you have commercial insurance but high copays:

  • HealthWell Foundation: Covers copays for eligible chronic conditions
  • Patient Advocate Foundation Co-Pay Relief: Income up to 400% of Federal Poverty Guidelines
  • PAN Foundation: Disease-specific assistance programs

Requesting Formulary Exceptions

When You Need an Exception

Request a formulary exception if:

  • Brand Keppra isn't on your formulary
  • You need brand over generic due to medical reasons
  • Your copay tier is higher than expected

Required Documentation

Your prescriber must submit a statement explaining:

  • Medical necessity: Why brand Keppra is required over generic
  • Prior trials: Specific generic medications tried, dates, doses, outcomes
  • Clinical rationale: Therapeutic failures, adverse reactions, or bioequivalence concerns
  • Patient details: Diagnosis (with ICD-10 if relevant), current symptoms, treatment goals

Clinician Corner: Medical Necessity Letter Checklist

✓ Patient identification: Name, DOB, member ID, diagnosis ✓ Clinical history: Seizure type, frequency, previous medications ✓ Generic trial documentation: Specific products, durations, reasons for discontinuation ✓ Medical justification: Why brand formulation is necessary (e.g., "Patient experienced breakthrough seizures on generic formulation despite therapeutic levels") ✓ Supporting evidence: Lab values, seizure logs, side effect documentation ✓ Treatment plan: Monitoring schedule, expected outcomes

Submission Process

  1. Complete form: Use your plan's formulary exception request form
  2. Submit promptly: Fax to number provided on form or submit via member portal
  3. Follow up: Standard decisions within 72 hours; expedited available if urgent
  4. Transition supply: Request up to 30-day emergency fill while pending

Retail vs. Mail-Order Pharmacy

Good news: Keppra/levetiracetam doesn't require specialty pharmacy dispensing under BCBS Ohio plans. You have flexibility in where you fill your prescription.

Retail Pharmacy Benefits

  • Immediate access to medication
  • Face-to-face consultation with pharmacist
  • Easier for dose adjustments or new prescriptions
  • No shipping delays or weather concerns

Mail-Order Advantages

  • Often lower copays for 90-day supplies
  • Automatic refills available
  • Convenient for stable, long-term medications
  • Some plans require mail-order for maintenance drugs
Tip: Ask your prescriber to write for a 90-day supply to maximize mail-order savings, but start with 30 days if this is a new medication.

Appeals Process in Ohio

If your initial coverage request is denied, Ohio provides robust appeal rights:

Internal Appeals (with BCBS Ohio)

Level 1 - Standard Appeal:

  • Timeline: File within 180 days of denial
  • Decision timeframe: 30 days for standard, 72 hours for expedited
  • Required documents: Denial letter, prescriber support, medical records
  • Submission: Via member portal, mail, or fax (check denial letter for specifics)

Level 2 - Second Internal Appeal:

  • Available if first appeal is denied
  • Same timeline and submission requirements

External Review (Ohio Department of Insurance)

When to use: After exhausting internal appeals or if BCBS improperly denies appeal rights Timeline: 180 days from final internal denial Process:

  1. Request external review through your health plan
  2. Plan notifies Ohio Department of Insurance
  3. Independent Review Organization (IRO) assigned
  4. Decision within 30 days (72 hours if expedited)
  5. Binding decision: If overturned, BCBS must cover the treatment

Ohio Department of Insurance Contact:

Important: Self-funded employer plans follow federal ERISA rules, not Ohio's external review process. However, many still provide similar independent review options.

Planning for Annual Changes

What Can Change Year to Year

  • Formulary updates: Drugs may move tiers or be removed
  • Copay amounts: Plan design changes affect out-of-pocket costs
  • Prior authorization requirements: New restrictions may be added
  • Pharmacy networks: Preferred pharmacies may change

Staying Prepared

Before January 1st each year:

  • Review your plan's updated formulary (usually available in October)
  • Compare costs if switching plans during open enrollment
  • Renew any manufacturer assistance programs
  • Stock up on current medication if formulary changes are expected

During the year:

  • Set calendar reminders for assistance program renewals
  • Keep documentation of successful treatments for future appeals
  • Monitor for formulary updates (plans can make changes mid-year with notice)

Conversation Scripts

Calling BCBS Ohio Member Services

"Hi, I'm calling to check coverage for my seizure medication. My member ID is [number]. Can you tell me what tier levetiracetam is on my formulary and what my copay would be for a 30-day and 90-day supply? Also, is brand Keppra covered, and would it require prior authorization?"

Requesting Prescriber Support

"I need help with insurance coverage for my Keppra prescription. BCBS is requiring documentation that brand is medically necessary over generic. Can you help me submit a formulary exception request? I can provide information about my previous experience with generic versions."

Pharmacy Cost Inquiry

"I'm picking up levetiracetam and want to confirm this is the lowest cost option. Can you check if a 90-day supply would be less expensive? Also, do you have information about manufacturer discount programs?"

Counterforce Health specializes in helping patients navigate complex insurance appeals for prescription medications. Their platform analyzes denial letters and creates targeted, evidence-based appeals that address specific payer criteria, potentially saving patients months of back-and-forth with insurance companies.

FAQ

Q: How long does BCBS Ohio take to approve prior authorization requests? A: Standard decisions are made within 72 hours of receiving complete documentation from your prescriber. Expedited requests (when delay could harm your health) are processed faster.

Q: What if levetiracetam isn't on my formulary at all? A: This is rare, but you can request a formulary exception. Your prescriber needs to document medical necessity and why alternative covered medications aren't appropriate.

Q: Can I appeal if I'm denied coverage while already taking Keppra? A: Yes. Mention that you're currently stable on the medication and that changing could disrupt seizure control. This strengthens your medical necessity argument.

Q: Does step therapy apply if I've tried other seizure medications outside of Ohio? A: Your medical history follows you. Document previous medication trials with your new Ohio prescriber, including dates, doses, and reasons for discontinuation.

Q: What's the difference between a coverage determination and an appeal? A: A coverage determination is the initial decision about whether to cover a medication. An appeal challenges that decision if it's unfavorable.

Q: Can I get emergency supplies while my appeal is pending? A: Many BCBS plans provide transition supplies (usually 30 days) for medications you're currently taking while coverage decisions are pending.

Q: What if my employer plan is self-funded? A: Self-funded plans follow federal ERISA rules rather than Ohio insurance law, but most provide similar appeal processes. Check your Summary Plan Description for specific procedures.

Q: How do I know if my plan covers brand Keppra? A: Check your formulary document or call member services. Even if it's not listed, you can request coverage through the exception process.

Counterforce Health helps patients and clinicians turn insurance denials into successful appeals by creating evidence-backed documentation that addresses specific payer criteria. Their platform streamlines the complex appeals process, helping ensure patients get access to needed medications like Keppra. Learn more about their services.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by specific plan and change over time. Always verify current information with your insurance company and consult your healthcare provider for medical decisions. For additional help with insurance appeals in Ohio, contact the Ohio Department of Insurance Consumer Services at 1-800-686-1526.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.