Fycompa — CareFirst (Caremark)
Primary generalized tonic-clonic seizures (adjunctive therapy)
Initial criteria
- For partial-onset seizures: Authorization may be granted when the requested drug is being prescribed for the treatment of partial-onset seizures (focal-onset seizures) and:
- • If the request is for Aptiom (eslicarbazepine) OR Fycompa (perampanel), the patient is age ≥ 4 years.
- • If the request is for Briviact (brivaracetam) OR Vimpat (lacosamide), the patient is age ≥ 1 month.
- • If the request is for Motpoly XR (lacosamide extended-release), the patient is an adult (age ≥ 17 years) OR a pediatric patient weighing ≥ 50 kg.
- • If the request is for Xcopri (cenobamate), the patient is an adult.
- For primary generalized tonic-clonic seizures (adjunctive therapy): Authorization may be granted when prescribed as adjunctive therapy for the treatment of primary generalized tonic-clonic seizures and:
- • If the request is for Fycompa (perampanel), the patient is age ≥ 12 years.
- • If the request is for Motpoly XR (lacosamide extended-release), the patient is an adult (age ≥ 17 years) OR a pediatric patient weighing ≥ 50 kg.
- • If the request is for Vimpat (lacosamide), the patient is age ≥ 4 years.
Approval duration
36 months