ELEPSIA XR (levetiracetam XR)
Self-Administration – Oral
Diagnosis considered for coverage:
- Seizures: Indicated as adjunctive therapy for the treatment of partial-onset seizures in patients 12 years of age and older.
Coverage Criteria:
For diagnosis of partial-onset seizures:
- Requested drug is being used for a Food and Drug Administration (FDA)-Approved indication; AND
- Dose does not exceed 3000mg/day; AND
- One of the following:
- Trial and failure of a minimum 30-day supply, or intolerance to generic levetiracetam extended-release.
- For continuation of prior therapy.
Reauthorization Criteria:
For diagnosis of partial-onset seizures:
- Dose does not exceed 3000mg/day; AND
- Documentation of positive clinical response to therapy
Coverage Duration:
- 1 year
Dosing:
- Initial dose of 1000 mg orally once daily.
- Titrate by increasing in increments of 1000 mg/day every 2 weeks up to 3000 mg/day.
Authorization is not covered for the following:
The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.
Additional Information:
- Elepsia XR should be taken whole and should not be crush, chew, or split.
- Not recommended for use in patients with moderate or severe renal impairment and recommending a maximum dose of 2000mg in mild renal impairment.
- Suicidal behavior and ideation can occur when taking Elepsia XR and patients should be monitored for unusual changes in mood or behavior.
- Patients taking Elepsia XR should watch out for any dermatological reaction including Steven-Johnson syndrome (SJS) and topic epidermal necrolysis (TEN) which occurs within 14-17 days of taking.
Policy Updates:
- 08/15/2023 – New policy approved by P&T.
References:
- Elepsia XR Prescribing Information. Tripoint Therapeutics, LLC. Westfield, NJ. December 2020.
Last review date: July 12, 2024