By Counterforce Health Team in Keppra (levetiracetam) —

How to Get Keppra (Levetiracetam) Covered by Cigna in Ohio: Complete Appeals Guide and Success Templates

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

Generic levetiracetam is typically Tier 1 on Cigna formularies and doesn't require prior authorization. Brand Keppra requires prior authorization with documented failure or intolerance to generic levetiracetam first (step therapy). If denied, you have 180 days to appeal internally, then can request external review through Ohio Department of Insurance within 60 days. First step today: Check your specific formulary tier at myCigna.com and gather seizure frequency logs plus neurologist notes showing medical necessity.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timeline and Urgency
  4. Medical Necessity Criteria
  5. Cost Information
  6. Denials and Appeals
  7. Ohio External Review Process
  8. Renewal Requirements
  9. Common Problems and Solutions
  10. Frequently Asked Questions

Coverage Basics

Is Keppra (Levetiracetam) Covered by Cigna?

Generic levetiracetam is covered on most Cigna plans as a Tier 1 medication with the lowest copays. Brand Keppra is no longer marketed in the U.S. by UCB, but if prescribed, it typically requires prior authorization and step therapy documentation.

Coverage at a Glance:

Requirement Generic Levetiracetam Brand Keppra (if available)
Prior Authorization Usually not required Required
Formulary Tier Tier 1 (lowest cost) Tier 3/4 (higher cost)
Step Therapy Not applicable Must try generic first
Quantity Limits May apply May apply
Specialty Pharmacy No (retail/mail order) No (retail/mail order)

Source: Cigna National Preferred Formulary

Which Cigna Plans Cover Levetiracetam?

Most Cigna commercial plans, Medicare Advantage, and employer-sponsored plans include levetiracetam on their formularies. Coverage specifics vary by plan type, so verify your exact benefits through the Cigna member portal.

Prior Authorization Process

Who Submits the Prior Authorization?

Your prescribing physician (typically a neurologist) submits the prior authorization request. You cannot submit it yourself, but you can help gather required documentation.

Step-by-Step: Fastest Path to Approval

  1. Physician Reviews Formulary - Doctor checks if generic levetiracetam is covered first
  2. Gather Medical Records - Collect seizure logs, EEG results, and prior medication trials
  3. Submit PA Request - Doctor submits via Cigna provider portal or fax
  4. Include Supporting Evidence - Medical necessity letter with clinical rationale
  5. Track Status - Monitor through provider portal or member services
  6. Receive Decision - Cigna responds within required timeframes
  7. Appeal if Denied - File internal appeal within 180 days if needed

Required Documentation for Brand Keppra

If requesting brand Keppra over generic, your neurologist must provide:

  • Documented trial of generic levetiracetam with specific dates, doses, and outcomes
  • Clinical evidence of failure or intolerance to generic formulation
  • Medical necessity letter explaining why brand is required
  • Supporting clinical notes from recent neurology visits
  • Seizure frequency documentation showing current control status

Source: Cigna Clinical Policy for Antiepileptics

Timeline and Urgency

How Long Does Cigna Prior Authorization Take?

  • Standard Review: Up to 15 business days for pre-service requests
  • Expedited Review: 72 hours when delay could jeopardize health
  • Post-Service Review: 30 days for claims already incurred

When to Request Expedited Review

Request expedited review if:

  • You're currently having breakthrough seizures
  • Delay in medication could worsen seizure control
  • Your neurologist certifies urgent medical need
Tip: For seizure medications, most requests qualify for expedited review due to the serious health risks of delayed treatment.

Medical Necessity Criteria

What Counts as Medical Necessity for Keppra (Levetiracetam)?

Cigna typically approves levetiracetam when documentation shows:

For Generic Levetiracetam:

  • Confirmed epilepsy diagnosis with appropriate ICD-10 codes
  • Clinical indication for antiepileptic therapy
  • Appropriate dosing for patient's weight and seizure type

For Brand Keppra (if available):

  • Generic failure: Documented inadequate seizure control after appropriate trial
  • Generic intolerance: Specific adverse reactions to generic formulation
  • Excipient allergy: Documented allergy to inactive ingredients in generic
  • Bioequivalence concerns: Clinical evidence of therapeutic differences
Clinician Corner: Medical necessity letters should reference FDA labeling for levetiracetam indications, include specific seizure frequency data, and cite relevant epilepsy treatment guidelines from the American Epilepsy Society.

Cost Information

Copay and Coinsurance for Levetiracetam

Typical Cigna Costs (verify with your specific plan):

Medication Type Tier Estimated Copay Notes
Generic levetiracetam Tier 1 $10-25 per fill Lowest cost option
Brand Keppra Tier 3/4 $50-150+ per fill Requires PA approval

Savings Options

  • Manufacturer programs: Check with generic manufacturers for patient assistance
  • GoodRx pricing: Generic levetiracetam often under $20 for common doses
  • 90-day supplies: May reduce per-fill costs through Express Scripts mail order

Source: GoodRx Levetiracetam Pricing

Denials and Appeals

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn Required Documentation
"Generic not tried first" Submit step therapy exception Generic trial records, failure documentation
"Not medically necessary" Provide clinical justification Neurologist letter, seizure logs, EEG results
"Incomplete documentation" Resubmit with all records Complete medical history, current treatment plan
"Quantity exceeds limits" Request quantity limit override Dosing rationale, clinical need for higher dose

Cigna Internal Appeals Process

Timeline for Appeals in Ohio:

  • File within: 180 days of denial notice
  • Standard review: 30 days for pre-service, 60 days for post-service
  • Expedited review: 72 hours for urgent medical situations

How to File Your Appeal:

  1. Gather denial letter and all supporting medical records
  2. Submit appeal via Cigna member portal or mail
  3. Include new evidence if available (updated neurologist letter, recent seizure data)
  4. Request peer-to-peer review between your neurologist and Cigna medical director
  5. Track your appeal through member portal or customer service

Source: Cigna Appeals Process

Ohio External Review Process

If Cigna upholds their denial after internal appeals, you can request an independent external review through the Ohio Department of Insurance.

Ohio External Review Requirements

  • Must complete: All levels of Cigna's internal appeal process first
  • File within: 60 days of final Cigna denial
  • Review timeline: 30 days for standard, 72 hours for expedited
  • Cost: Free to patients
  • Decision: Binding on Cigna if overturned

How to Request External Review in Ohio

  1. Contact Ohio Department of Insurance at 1-800-686-1526
  2. Submit external review form (provided in your final denial letter)
  3. Include all documentation from your case
  4. Wait for IRO assignment - Independent Review Organization will be selected
  5. Provide additional evidence if requested by IRO
  6. Receive binding decision within required timeframe
Note: Ohio's external review process is consumer-friendly - even if Cigna claims your case isn't eligible, the Ohio Department of Insurance can independently determine eligibility and order a review.

Source: Ohio Department of Insurance External Review

Counterforce Health helps patients and providers navigate complex prior authorization and appeals processes by analyzing denial letters, identifying specific policy requirements, and drafting evidence-backed appeals that address each payer's unique criteria. Their platform streamlines the appeals process by pulling relevant clinical guidelines and organizing documentation to meet insurer-specific requirements.

Renewal Requirements

When to Re-authorize Keppra (Levetiracetam)

Most Cigna prior authorizations for antiepileptic drugs are valid for:

  • Initial approval: 6-12 months
  • Renewal requirements: Updated clinical notes showing continued medical necessity
  • Automatic renewal: May apply for stable, long-term therapy

What Changes Trigger New Prior Authorization

  • Change from generic to brand formulation
  • Significant dose increases beyond approved quantity limits
  • Addition of new indications or off-label use
  • Plan year changes or switching Cigna plan types

Common Problems and Solutions

Troubleshooting Cigna Prior Authorization Issues

Problem: "Portal shows no prior auth needed, but pharmacy says it's required" Solution: Call Cigna member services to verify current PA status and get reference number

Problem: "Neurologist submitted PA but no response from Cigna" Solution: Track submission through provider portal; follow up if approaching deadline

Problem: "Approved for generic but need brand Keppra" Solution: Submit new PA request with brand medical necessity documentation

Problem: "Prior auth expired and pharmacy won't fill" Solution: Contact prescriber to submit renewal request; may need temporary supply

From Our Advocates: We've seen cases where patients received approvals for generic levetiracetam but still faced pharmacy rejections due to quantity limits. The key was having the neurologist submit a quantity limit override with clinical justification for the prescribed dose - most were approved within 48 hours once proper documentation was provided.

Frequently Asked Questions

Q: How long does Cigna prior authorization take for Keppra in Ohio? A: Standard reviews take up to 15 business days, but expedited reviews for seizure medications are typically completed within 72 hours due to medical urgency.

Q: What if Keppra is non-formulary on my Cigna plan? A: You can request a formulary exception by having your neurologist submit clinical documentation showing medical necessity and why formulary alternatives aren't appropriate.

Q: Can I request an expedited appeal if Cigna denies Keppra? A: Yes, if your neurologist certifies that delay could jeopardize your health or seizure control, you can request expedited internal appeal (72 hours) and expedited external review in Ohio.

Q: Does step therapy apply if I've been on Keppra from another state? A: Existing therapy history should be considered, but Cigna may still require documentation of generic levetiracetam trial. Provide complete medication history to support continuation.

Q: What happens if I can't afford the copay for brand Keppra? A: Since brand Keppra is no longer marketed in the U.S., focus on generic levetiracetam options and explore manufacturer assistance programs or pharmacy discount programs.

Q: How do I know if my Cigna plan covers levetiracetam? A: Log into your myCigna account and use the "Price a Medication" tool, or call member services with your plan details.

Q: Can my pharmacy help with the prior authorization process? A: Pharmacies can initiate prior authorization requests and provide forms to your doctor, but the prescribing physician must complete and submit the actual request with clinical documentation.

Q: What if Cigna requires peer-to-peer review for Keppra approval? A: Your neurologist will speak directly with a Cigna medical director to discuss clinical rationale. This often resolves denials when proper medical necessity is explained by a specialist.

When dealing with insurance coverage challenges, Counterforce Health provides specialized support by analyzing payer policies, identifying specific denial reasons, and helping craft targeted appeals that address each insurer's unique requirements and documentation standards.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and is not medical or legal advice. Insurance coverage policies change frequently, and individual circumstances vary. Always verify current coverage details with your specific Cigna plan and consult with your healthcare provider about appropriate treatment options. For personalized assistance with Ohio insurance appeals, contact the Ohio Department of Insurance Consumer Services Division at 1-800-686-1526.

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