XCOPRI (cenobamate)
SELF ADMINISTRATION - ORAL
Indications for Prior Authorization:
Partial onset seizures in adult patients
Coverage Criteria:
- Age 18 years and older; AND
- Prescribed by or in consultation with a neurologist; AND
- Failure of two preferred anticonvulsants indicated for partial seizures; AND
- Dose does not exceed 400 mg per day.
Dosing:
Starting dose: 12.5 mg once daily, titrated to the recommended maintenance dosage of 200 mg once daily.
If needed based on clinical response and tolerability, the dose may be increased above 200 mg by increments of 50 mg every two weeks up to 400 mg. The recommended titration schedule should not be exceeded.
Maximum dose: 400 mg once daily.
Coverage Duration:
1 year
Authorization is Not Covered for the Following:
Non-FDA approved indications that are not listed in this policy do not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics Committee.
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