By Counterforce Health Team in Keppra (levetiracetam) —

How to Get Keppra (Levetiracetam) Covered by Cigna in Michigan: Prior Authorization, Appeals, and Cost Savings Guide

Answer Box: Getting Keppra (Levetiracetam) Covered by Cigna in Michigan

Generic levetiracetam is typically covered on Cigna formularies as Tier 1 ($5-15 copay) without prior authorization. Brand Keppra requires step therapy (try generic first) and prior authorization. If denied, you have 180 days for internal appeals, then 127 days for Michigan's external review through DIFS. Start today: Check your specific formulary at cigna.com/druglist, and if denied, request a formulary exception with clinical documentation of generic failure or medical necessity.

Table of Contents

Coverage at a Glance

Requirement Generic Levetiracetam Brand Keppra Where to Verify
Formulary Status Tier 1-2 (preferred) Tier 3-4 (non-preferred) Cigna Drug List
Prior Authorization Usually not required Required Plan-specific formulary
Step Therapy No Yes (try generic first) Coverage determination
Quantity Limits Rare May apply Pharmacy benefit summary
Copay Range $5-40/month $40-100+/month Evidence of Coverage
Appeals Deadline 180 days (internal) 180 days (internal) Cigna Coverage Decisions
Michigan External Review 127 days after final denial 127 days after final denial Michigan DIFS

Step-by-Step: Fastest Path to Approval

1. Check Your Formulary Status

Who: Patient or caregiver
Action: Visit cigna.com/druglist and search "levetiracetam" and "Keppra"
Timeline: 5 minutes
What you'll find: Tier placement, any restrictions (PA, QL, ST)

2. Try Generic First (If Not Already)

Who: Prescriber
Action: Prescribe generic levetiracetam if clinically appropriate
Timeline: Standard pharmacy fill
Documentation: Note any previous generic trials in medical record

3. Document Medical Necessity (If Brand Needed)

Who: Prescriber
Action: Gather evidence of generic failure, intolerance, or contraindication
Timeline: 1-2 days
Required: Seizure diary, side effects log, prior pharmacy records

4. Submit Prior Authorization

Who: Prescriber's office
Action: Use CoverMyMeds portal or fax Cigna PA form
Timeline: 72 hours (standard) or 24 hours (expedited)
Include: Clinical notes, diagnosis codes, treatment history

5. Request Formulary Exception (If Non-Formulary)

Who: Prescriber
Action: Submit formulary exception request with clinical justification
Timeline: 2-5 business days
Form: Pharmacy Formulary Exception

6. Appeal If Denied

Who: Patient, prescriber, or authorized representative
Action: File internal appeal within 180 days of denial
Timeline: 30-60 days for decision
Next step: Michigan external review if still denied

7. File External Review (If Needed)

Who: Patient or representative
Action: Submit to Michigan DIFS within 127 days of final internal denial
Timeline: Up to 60 days (72 hours if expedited)
Contact: Michigan DIFS at 877-999-6442

Understanding Your Cigna Benefits

When you're prescribed Keppra (levetiracetam), the first thing to understand is how Cigna structures its drug coverage. Most Cigna plans use a tiered formulary system where generic levetiracetam typically sits on Tier 1 or 2 with the lowest copays—often $5-15 for a 30-day supply.

The challenge comes when you need brand-name Keppra specifically. Brand Keppra is no longer actively marketed in the U.S. by UCB, but some patients may have medical reasons requiring the original formulation. When this happens, Cigna's step therapy protocols kick in.

Tip: Before assuming you need brand Keppra, discuss with your neurologist whether generic levetiracetam would be clinically equivalent for your specific situation. Many patients successfully transition to generics with proper monitoring.

What Drives Your Costs

Your out-of-pocket costs depend on several benefit design factors:

  • Formulary tier: Lower tiers mean lower copays
  • Deductible status: Whether you've met your annual deductible
  • Pharmacy choice: Retail vs. mail-order vs. specialty pharmacy
  • Supply length: 30-day vs. 90-day fills often have different cost structures

Prior Authorization Requirements

Cigna typically requires prior authorization for brand Keppra, following a two-step therapy approach. Here's what your doctor needs to document:

Clinical Documentation Checklist

  • Epilepsy diagnosis with specific ICD-10 code (e.g., G40.909 for unspecified epilepsy)
  • Generic trial details: Specific doses tried, duration of each trial, documented failure reasons
  • Seizure frequency data: Before and during generic trials
  • Side effects or intolerance: Specific symptoms, severity, impact on daily function
  • Prior hospitalizations or ER visits related to seizure control
  • Current seizure control status and treatment goals

Submission Process

The fastest route is through CoverMyMeds, which electronically connects your prescriber to Cigna's system. Alternatively, your doctor can:

  • Fax completed PA forms to Cigna's dedicated line
  • Call 1-800-882-4462 for urgent cases
  • Submit through Cigna's provider portal

Standard review takes 72 hours for most requests, but expedited reviews (24 hours) are available when health would be jeopardized by delays.

Formulary Exception Process

If Keppra isn't covered at all on your plan, or if you need an exception to step therapy requirements, Cigna offers a formulary exception process. Your physician must certify in writing that:

  • The required step therapy drug is expected to be ineffective based on your clinical characteristics
  • The required drug is not clinically appropriate (e.g., worsens other conditions)
  • You're stable on Keppra under a current or prior plan, and switching would cause harm
  • You've already tried step therapy drugs with lack of efficacy or adverse events

The formulary exception form requires detailed clinical justification from your prescriber.

Specialty vs. Retail Pharmacy

For most levetiracetam prescriptions, you can fill at your regular retail pharmacy. However, Cigna may require certain formulations or high-dose prescriptions to go through Accredo, their specialty pharmacy partner.

When Accredo is Required

  • High-dose levetiracetam prescriptions
  • Specific formulations designated as specialty
  • Certain combination therapies

Benefits of Accredo

  • Free home delivery with temperature control
  • 24/7 pharmacist and nurse support
  • Medication adherence monitoring
  • Copay assistance program coordination
  • Automatic refill reminders

If your prescription requires Accredo, your doctor will fax the prescription directly to 888-302-1028, and Accredo will contact you within 24-48 hours to set up delivery and coordinate any prior authorizations.

Appeals Process in Michigan

Michigan provides strong patient protections for insurance denials. If Cigna denies your Keppra coverage, you have multiple levels of appeal available.

Internal Appeals (First Step)

  • Timeline: Must file within 180 days of denial
  • Process: Submit written appeal to Cigna with additional clinical documentation
  • Decision timeframe: 30 days for standard appeals, 72 hours for expedited
  • Who can file: Patient, prescriber, or authorized representative

Michigan External Review (Final Step)

Michigan's Department of Insurance and Financial Services (DIFS) oversees external reviews when internal appeals are exhausted.

Key Details:

  • Filing deadline: 127 days after final internal denial
  • Cost: Free to patients
  • Timeline: Up to 60 days (72 hours for expedited cases)
  • Contact: 877-999-6442 or online at Michigan.gov/DIFS

To request expedited external review, you need a physician letter stating that waiting would seriously jeopardize your health.

From our advocates: We've seen Michigan external reviews successfully overturn Cigna denials when patients provide comprehensive seizure diaries and neurologist letters explaining why generic alternatives failed. The key is thorough documentation of the medical necessity.

Cost Savings and Assistance Programs

Manufacturer Assistance

UCB offers patient assistance through UCBCares for eligible patients:

  • Income limit: Up to 500% of Federal Poverty Level
  • Coverage: Free medication for uninsured; copay assistance for commercially insured
  • Duration: Up to 24 months with 90-day re-verification
  • Exclusions: Medicare, Medicaid, TRICARE patients ineligible

Michigan-Specific Resources

The Epilepsy Foundation of Michigan offers emergency medication assistance:

  • Coverage: Up to $250 for 30-day supply
  • Eligibility: Michigan residents with confirmed epilepsy diagnosis
  • Process: Application with prescription, followed by phone consultation
  • Contact: 800-377-6226

General Assistance Options

Counterforce Health helps patients navigate insurance denials by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed appeals. Their platform identifies the specific denial basis and drafts point-by-point rebuttals aligned to your plan's own rules, potentially saving weeks in the appeals process.

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Required Documentation
Generic available Prove generic failure/intolerance Seizure diary, side effects log, pharmacy records
Step therapy incomplete Document adequate generic trial Dose escalation records, duration of trials, outcomes
Not medically necessary Specialist letter + clinical evidence EEG results, seizure frequency data, hospitalization records
Quantity limits exceeded Justify high-dose requirement Weight-based calculations, blood level monitoring
Non-formulary drug Request formulary exception Comparative effectiveness data, contraindications to alternatives

Scripts for Key Conversations

Calling Cigna Customer Service

"Hi, I'm calling about a prior authorization denial for Keppra. My member ID is [number]. I need to understand the specific denial reason and what documentation would support an appeal. Can you also confirm the appeals deadline and process?"

Requesting Peer-to-Peer Review

"This is Dr. [name] requesting a peer-to-peer review for patient [name], member ID [number], regarding denied coverage for Keppra. The patient has documented failure of generic levetiracetam with increased seizure frequency. When can we schedule this review?"

Pharmacy Coordination

"I need to transfer my Keppra prescription from retail to Accredo. Can you help coordinate this transfer and ensure there's no gap in my medication while the prior authorization is processed?"

FAQ

Q: How long does Cigna prior authorization take for Keppra?
A: Standard reviews take 72 hours, expedited reviews take 24 hours. The clock starts when Cigna receives complete clinical documentation.

Q: What if Keppra is completely non-formulary on my plan?
A: You can request a formulary exception with clinical justification. Your doctor must demonstrate medical necessity and why formulary alternatives aren't appropriate.

Q: Can I get expedited appeals in Michigan?
A: Yes, both Cigna internal appeals and Michigan external reviews offer expedited processes when delays would jeopardize your health.

Q: Does step therapy apply if I was stable on Keppra with a previous insurer?
A: You may qualify for a step therapy exception if you can document prior stability. Provide pharmacy records and clinical notes from your previous coverage.

Q: What's the difference between a coverage determination and prior authorization?
A: Prior authorization is required before filling the prescription. A coverage determination is Cigna's formal decision about whether they'll cover the drug under your specific circumstances.

Q: Can I appeal if my copay is too high?
A: You can request a tier exception to move Keppra to a lower copay tier, but this requires clinical justification for why lower-tier alternatives aren't appropriate.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies and state regulations may change. Always verify current requirements with your specific plan and consult healthcare providers for medical decisions. For personalized assistance with insurance appeals and prior authorizations, Counterforce Health provides specialized support in navigating coverage denials with evidence-backed appeal strategies.

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