By Counterforce Health Team in Keppra (levetiracetam) —

How to Get Keppra (levetiracetam) Covered by Cigna in Texas: Prior Authorization, Appeals, and Step Therapy Guide

Answer Box: Getting Keppra Covered by Cigna in Texas

Generic levetiracetam is typically covered without prior authorization on Cigna plans, while brand Keppra requires step therapy (trying generic first) and prior authorization. To get coverage: 1) Ask your doctor if generic levetiracetam works for your seizure type, 2) If brand Keppra is medically necessary, have your provider submit a prior authorization with documentation of generic failure/intolerance, 3) File internal appeals within 180 days if denied, followed by external review through Texas Department of Insurance if needed. Start by checking your specific formulary at Cigna's member portal or calling member services.

Table of Contents

Coverage at a Glance

Requirement Levetiracetam (Generic) Keppra (Brand) Source
Formulary Tier Tier 1 (Generic) Tier 3 (Non-preferred Brand) Cigna National Formulary
Prior Authorization No Yes Cigna Coverage Policy
Step Therapy N/A Must try generic first Cigna Step Therapy Policy
Quantity Limits No Varies by plan Express Scripts Formulary
Appeals Deadline 180 days 180 days Texas Insurance Code

Plan Types & Network Implications

HMO vs. PPO Considerations

HMO plans require referrals from your primary care physician to see a neurologist or epilepsy specialist. If you need Keppra, ensure your PCP refers you to an in-network neurologist who can prescribe and manage your treatment.

PPO plans allow direct access to specialists but may have higher out-of-network costs. For specialty medications like Keppra, staying in-network is crucial for coverage.

EPO plans combine elements of both but don't cover out-of-network care except in emergencies.

Tip: Texas has strong patient protections for specialty drug access, but network requirements still apply. Verify your neurologist is in-network before starting the prior authorization process.

Formulary Status & Tier Placement

Generic Levetiracetam: The Preferred Path

Generic levetiracetam sits on Tier 1 of most Cigna formularies, meaning:

  • Lowest copay (typically $5-15 for a 30-day supply)
  • No prior authorization required
  • No step therapy requirements
  • Available in multiple formulations: tablets, extended-release, and oral solution

Brand Keppra: Higher Tier, More Restrictions

Brand Keppra is classified as Tier 3 (Non-preferred Brand), which means:

  • Higher copays (often $40-80 for a 30-day supply)
  • Prior authorization required
  • Must try generic levetiracetam first (step therapy)
  • May have quantity limits depending on your specific plan

Important note: Brand Keppra and Keppra XR are no longer actively marketed in the U.S. by UCB, though some pharmacies may still have inventory. Most patients are successfully treated with generic levetiracetam.

Step Therapy Requirements

Cigna implements a two-step tier system for levetiracetam products:

Step 1: Required First Trial

You must try generic levetiracetam before Cigna will approve brand Keppra. This includes:

  • Levetiracetam tablets (immediate-release)
  • Levetiracetam extended-release tablets
  • Levetiracetam oral solution

Step 2: Brand Access After Generic Trial

Brand Keppra becomes available only after documenting:

  • Inadequate response to generic levetiracetam despite adequate trial duration
  • Intolerance to generic formulation (specific side effects documented)
  • Medical contraindication to generic ingredients

Exception: Previous Use

If you previously took brand Keppra and discontinued it, you may qualify for re-approval without repeating the generic trial, provided your doctor documents the previous use and medical necessity for returning to the brand.

Prior Authorization Process

Required Documentation

When your doctor submits a prior authorization for Keppra, they must include:

Clinical Information:

  • Epilepsy diagnosis with specific seizure type
  • ICD-10 codes (e.g., G40.909 for epilepsy, unspecified)
  • Documentation of generic levetiracetam trial with:
    • Dosage and duration tried
    • Specific reasons for inadequate response or intolerance
    • Timeline of seizure frequency before/during generic trial

Supporting Evidence:

  • Recent EEG results if available
  • Seizure diary or frequency log
  • Previous hospitalization records for seizures
  • Letter of medical necessity from prescribing neurologist

Submission Methods

Fastest: Electronic submission through CoverMyMeds portal

Alternative: Fax completed Cigna Prior Authorization Form to your state-specific number (verify current fax number with Cigna)

Phone: Call 1-800-882-4462 for urgent cases

Timeline Expectations

  • Standard review: 5 business days
  • Urgent review: 72 hours (when delay could endanger health)
  • Automatic approval: If Cigna doesn't respond within required timeframe

Specialty Pharmacy Requirements

For certain Keppra formulations or high-dose prescriptions, Cigna may require fulfillment through their specialty pharmacy partner, Accredo.

Enrollment Process

  1. Provider submits prescription directly to Accredo (Fax: 888-302-1028)
  2. Patient enrollment call from Accredo within 24-48 hours
  3. Prior authorization coordination between Accredo and Cigna
  4. Delivery setup with temperature-controlled shipping if needed

Accredo Services Include:

  • Free home delivery
  • Refill reminders via phone, text, or app
  • Clinical support from specialty pharmacists
  • Side effect monitoring and management
  • Insurance coordination and copay assistance programs

Contact Accredo: 800-803-2523 or through the Accredo patient portal

Appeals Process in Texas

Internal Appeal (First Level)

Timeline: File within 180 days of denial notice Decision timeframe: 30 days standard, 72 hours expedited

Required documents:

  • Original denial letter
  • Cigna member ID card
  • Medical records supporting necessity for Keppra
  • Letter from neurologist explaining why generic failed
  • Seizure frequency documentation

Submission: Mail to address on denial letter or submit through Cigna member portal

External Review (Independent Review Organization)

If internal appeal is denied, Texas law provides access to binding external review.

Timeline: Request within 4 months of final internal denial Decision timeframe: 20 days standard, 72 hours expedited Cost: Free to patient (Cigna pays IRO fees)

How to request: Use IRO request form provided with final denial letter, or contact Texas Department of Insurance at 1-800-252-3439

Note: External review decisions are binding on Cigna. If the IRO overturns the denial, Cigna must provide coverage.

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Required Documentation
"Generic available" Document generic failure/intolerance Seizure diary, side effect log, dose escalation attempts
"Not medically necessary" Provide epilepsy specialist letter EEG results, treatment history, seizure frequency data
"Step therapy not completed" Document adequate generic trial Pharmacy records, duration of trial, response measurements
"Quantity exceeds limits" Justify higher dose medically Weight-based dosing calculations, blood levels, specialist recommendation

Clinician Corner: Medical Necessity Letter Checklist

When writing a letter to support Keppra coverage, include:

✅ Patient's seizure disorder diagnosis with specific type and ICD-10 code ✅ Previous treatments tried with specific medications, doses, and durations ✅ Documented failures including inadequate seizure control or intolerable side effects ✅ Clinical rationale for why Keppra is uniquely necessary ✅ Treatment goals and expected outcomes ✅ References to FDA labeling or epilepsy treatment guidelines ✅ Monitoring plan for efficacy and safety

Cost-Saving Options

Manufacturer Support

While brand Keppra is no longer actively marketed, UCB may still honor existing patient assistance programs. Contact UCB Patient Support at 1-844-599-2273 to verify current programs.

Generic Alternatives

Generic levetiracetam offers significant savings:

  • GoodRx: Often under $20 for 60 tablets (500mg)
  • Costco Pharmacy: Competitive generic pricing without membership for prescriptions
  • Walmart $4 List: Check if levetiracetam is included in your area

Texas State Programs

  • Texas Medicaid: Covers levetiracetam with prior authorization for certain formulations
  • CHIP: Children's coverage includes seizure medications with appropriate documentation

Counterforce Health helps patients navigate these coverage challenges by analyzing denial letters, identifying the specific reasons for rejection, and crafting targeted appeals with evidence-backed arguments. Their platform streamlines the prior authorization and appeals process, potentially saving weeks of back-and-forth with insurers while improving approval rates for medically necessary treatments.

FAQ

How long does Cigna prior authorization take for Keppra in Texas?

Standard prior authorization decisions are made within 5 business days. Urgent requests (when delay could harm your health) are processed within 72 hours. If Cigna doesn't respond within the required timeframe, the request is automatically approved.

What if Keppra is completely non-formulary on my plan?

You can request a formulary exception through the same prior authorization process. Your doctor must demonstrate that all formulary alternatives are medically inappropriate or have been tried unsuccessfully.

Can I request an expedited appeal in Texas?

Yes. If waiting for a standard appeal could seriously jeopardize your health, you can request expedited review. Both internal appeals (72 hours) and external reviews (72 hours) have expedited options when medical urgency is documented.

Does step therapy apply if I was stable on Keppra before moving to Texas?

Previous use may qualify you for an exception to step therapy requirements. Your doctor should document your previous stable response to Keppra and request continuation of existing therapy in the prior authorization.

What's the difference between brand Keppra and generic levetiracetam?

Both contain the same active ingredient (levetiracetam) and are FDA-approved as therapeutically equivalent. Generic versions must meet the same bioequivalence standards. Most patients transition successfully, but some may experience differences in side effects or seizure control due to different inactive ingredients.

Who can help me navigate Cigna appeals in Texas?

  • Texas Department of Insurance: 1-800-252-3439
  • Office of Public Insurance Counsel: 1-877-611-6742
  • Disability Rights Texas: Provides advocacy for medication access
  • Counterforce Health: Specializes in turning insurance denials into successful appeals

Are there special rules for children needing Keppra?

Pediatric dosing may require higher per-kilogram doses, which could trigger quantity limit reviews. Your pediatric neurologist should document weight-based dosing calculations and reference FDA pediatric labeling in prior authorization requests.

What if I'm on a self-funded employer plan?

Self-funded ERISA plans follow federal rather than Texas state appeal rules. You'll still have internal and external review rights, but timelines and processes may differ. Check your Summary Plan Description for specific procedures.

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider regarding treatment decisions and insurance coverage options.

Sources & Further Reading

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