Pharmacy Prior Authorization Criteria

Anticonvulsants

Indications for Prior Authorization

Briviact (brivaracetam)

• For diagnosis of Partial-Onset Seizures
  Indicated for the treatment of partial-onset seizures in patients 1 month of age and older.

Criteria

Briviact tablet, oral solution

Step Therapy

Length of Approval: 12 Month(s)

• BOTH of the following:
• Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
AND
• Trial and failure (of a minimum 30-day supply), contraindication or intolerance to one of the following generics:
• lamotrigine immediate-release (IR)
• levetiracetam IR
• levetiracetam extended-release (ER)
• oxcarbazepine IR
• topiramate IR
OR
• For continuation of prior therapy

P & T Revisions

2024-03-18, 2023-02-27, 2022-02-04, 2021-10-13, 2021-09-27, 2021-05-18, 2021-03-03, 2020-02-19, 2019-12-10

References

1. Briviact Prescribing Information. UCB, Inc. Smyrna, GA. September 2021.

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Revision History

• 2024-03-18: Annual Review
• 2023-02-27: Annual Review - no criteria changes
• 2022-02-04: Annual Review - Addition of diagnosis check
• 2021-10-13: Updated indication section due to Briviact expanded approval to age 1 month and up. No change to clinical criteria.
• 2021-09-27: EHB specific guideline, added to EHB formulary, removed from OptumRx formulary. no changes to criteria
• 2021-05-18: EHB specific guideline, added to EHB formulary, removed from OptumRx formulary. no changes to criteria
• 2021-03-03: 2021 Annual Review, no changes to criteria.
• 2020-02-19: 2020 Annual Review, no changes to criteria.
• 2019-12-10: New EHB guideline that targets Briviact.

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