Pharmacy Prior Authorization Criteria

Anticonvulsants

Indications for Prior Authorization

Trokendi XR (topiramate extended-release)

• For diagnosis of Monotherapy Epilepsy
  Indicated as initial monotherapy for the treatment of partial-onset or primary generalized tonic-clonic seizures in patients 6 years of age and older

• For diagnosis of Adjunctive Therapy Epilepsy
  Indicated as adjunctive therapy for the treatment of partial-onset seizures, primary generalized tonic-clonic seizures, and seizures associated with Lennox-Gastaut syndrome in patients 6 years of age and older

• For diagnosis of Migraine
  Indicated for the preventive treatment of migraine in patients 12 years of age and older

Qudexy XR (topiramate extended-release)

• For diagnosis of Monotherapy Epilepsy
  Indicated as initial monotherapy for the treatment of partial-onset or primary generalized tonic-clonic seizures in patients 2 years of age and older.

• For diagnosis of Adjunctive Therapy Epilepsy
  Indicated as adjunctive therapy for the treatment of partial-onset seizures, primary generalized tonic-clonic seizures, and seizures associated with Lennox-Gastaut Syndrome in patients 2 years of age and older.

• For diagnosis of Migraine
  Indicated for the preventive treatment of migraine in patients 12 years of age and older.

Eprontia (topiramate oral solution)

• For diagnosis of Monotherapy Epilepsy
  Indicated as initial monotherapy for the treatment of partial-onset or primary generalized tonic-clonic seizures in patients 2 years of age and older.

• For diagnosis of Adjunctive Therapy Epilepsy
  Indicated as adjunctive therapy for the treatment of partial-onset seizures, primary generalized tonic-clonic seizures, and seizures associated with Lennox-Gastaut syndrome in patients 2 years of age and older.

• For diagnosis of Migraine
  Indicated for the preventive treatment of migraine in patients 12 years and older.

Oxtellar XR (oxcarbazepine extended-release)

• For diagnosis of Partial-onset seizures
  Indicated for the treatment of partial-onset seizures in patients 6 years of age and older.

Briviact (brivaracetam)

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

Xcopri (cenobamate)

• For diagnosis of Partial-onset seizures
  Indicated for the treatment of partial-onset seizures in adult patients.

Elepsia XR (levetiracetam extended-release)

• For diagnosis of Partial-onset seizures
  Indicated as adjunctive therapy for the treatment of partial-onset seizures in patients 12 years of age and older.

Motpoly XR (lacosamide extended-release)

• For diagnosis of Partial-onset seizures
  Indicated for the treatment of partial-onset seizures in adults and pediatric patients weighing at least 50 kg.

Criteria

Brand Qudexy XR, Brand Trokendi XR, generic topiramate ER

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) or intolerance to generic topiramate immediate-release (IR) tablet or topiramate IR sprinkle capsule.
OR
• For continuation of prior therapy

Eprontia

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) or intolerance to generic topiramate IR sprinkle capsules
OR
• For continuation of prior therapy

Brand Oxtellar XR, Generic oxcarbazepine extended-release

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) or intolerance to generic oxcarbazepine immediate-release (IR)
OR
• For continuation of prior therapy

Briviact

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

Xcopri

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

Elepsia XR

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) or intolerance to generic levetiracetam extended-release
OR
• For continuation of prior therapy

Motpoly XR

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) or intolerance to generic lacosamide IR
OR
• For continuation of prior therapy

P & T Revisions

2024-10-02, 2024-06-05, 2024-03-04, 2023-11-29, 2023-02-28, 2023-02-07, 2022-02-18, 2021-12-07, 2021-10-26, 2021-10-05, 2021-06-02, 2021-03-03, 2020-05-28, 2020-04-29, 2020-02-19

References

1. Trokendi XR Prescribing Information. Supernus Pharmaceuticals, Inc. Rockville, MD. December 2020.
2. Qudexy XR Prescribing Information. Upsher-Smith Laboratories, LLC. Maple Grove, MN. September 2020.
3. Oxtellar XR Prescribing Information. Supernus Pharmaceuticals, Inc. Rockville, MD. December 2020.
4. Briviact Prescribing Information. UCB, Inc. Smyrna, GA. September 2021.
5. Xcopri Prescibing Information. SK Life Science, Inc. Paramus, NJ. April 2021.
6. Elepsia XR Prescribing Information. Tripoint Therapeutics, LLC. Westfield, NJ. December 2020.
7. Eprontia Prescribing Information. Tulex Pharmaceuticals, Inc. Cranbury Township, NJ. November 2021.
8. Motpoly XR Prescribing Information. Aucta Pharmaceuticals, Inc. Piscataway, NJ. May 2023.

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Revision History

• 2024-10-02: Apply ST to generic oxcabazepine extended - release
• 2024-06-05: Addition of new Xcopri 25mg tablet as target
• 2024-03-04: Annual Review - No criteria changes
• 2023-11-29: Added Motpoly XR as a target to program
• 2023-02-28: Annual Review - Trokendi XR, generic topiramate ER, Qudexy XR criteria bucket revised to require trial and failure of a minimum 30 day supply or intolerance to generic topiramate immediate-release (IR) tablet or topiramate IR sprinkle capsule.
• 2023-02-07: Added generic Trokendi XR capsules to guideline with criteria to mirror their brand. No changes to criteria.
• 2022-02-18: Annual Review - Addition of diagnosis check. Copied over Eprontia updates from GL-103121 approved at Feb P&T
• 2021-12-07: Addition of Eprontia
• 2021-10-26: Added Elepsia XR to program, removed Topiramate ER as a target since this is now a true generic for Qudexy XR.
• 2021-10-05: Updated indication section due to Briviact expanded approval to age 1 month and up. No change to clinical criteria.
• 2021-06-02: Added new Xcopri GPI New 250 mg daily dose pack (100 mg and 150 mg tablets).
• 2021-03-03: 2021 Annual Review, no changes to criteria.
• 2020-05-28: Update product search to repopulate UMCS with Xcopri. No change to criteria.
• 2020-04-29: Added Xcopri as target to program
• 2020-02-19: Removed Gralise criteria (now added to Neurologic Agents guideline).

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