Subject: Briviact PA Policy 1337-A 06-2022

Drug

BRIVIACT  (brivaracetam)

Policy:

FDA-APPROVED INDICATIONS          
Briviact is indicated for the treatment of partial-onset seizures in patients 1 month of age and older. 

COVERAGE CRITERIA
The requested drug will be covered with prior authorization when the following criteria are met:
   •   The requested drug is being prescribed for the treatment of partial-onset seizures (i.e., focal-onset seizures)
        in a patient 1 month of age or older

Place of Service:

Outpatient

The above policy is based on the following references:

1. Briviact [package insert]. Smyrna, GA: UCB, Inc.; August 2021.
2. Lexicomp Online, AHFS DI (Adult and Pediatric) Online, Hudson, Ohio: UpToDate, Inc.; 2022; Accessed March 17, 2022.
3. Micromedex (electronic version). IBM Watson Health, Greenwood Village, Colorado, USA. Available at: https://www.micromedexsolutions.com. Accessed March 17, 2022.
4. Fisher RS, Cross JH, French JA, et al. Operational Classification of seizure types by the International League Against Epilepsy: Position Paper of the ILAE Commission for Classification and Terminology. 2017 Apr;58(4):522-530.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

October 15, 2022