Xcopri — Medical Mutual

Initial criteria

• Patient is age ≥ 18 years
• Patient does NOT have Familial Short QT syndrome
• Patient’s seizures have been inadequately controlled with prior use of at least one anti-epileptic drug (AED) (e.g., carbamazepine, divalproex, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, phenytoin, pregabalin, topiramate, valproic acid, zonisamide)
• Xcopri is prescribed by or in consultation with a physician who specializes in the condition being treated

Reauthorization criteria

• Documentation of response to therapy is required for continuation of therapy

Approval duration

2 years