Varies by plan

Does Blue Cross Blue Shield (affiliate) require prior authorization for Spritam?

Prior authorization for Spritam differs across Blue Cross Blue Shield (affiliate)'s Medicare Part D plans and product strengths — 2 of 2 Spritam products in the corpus appear on their formularies, and the requirement is not uniform. Check the member's specific plan.

Some plans require authorization and others do not. The member's specific plan decides.

Prior authorization requirements differ across this payer's plans: 83 of 269 covering plans require it. Check the specific plan the member is enrolled in — the plan name and contract number are on their insurance card.

By product strength

RxNorm product	Plans covering	Require prior auth	Step therapy	Qty limit	Status
levetiracetam 250 MG Tablet for Oral Suspension [Spritam]1736047	269 / 269	83	0	96	Varies by plan
levetiracetam 500 MG Tablet for Oral Suspension [Spritam]1736050	269 / 269	83	0	96	Varies by plan

Product names come from RxNorm (U.S. National Library of Medicine).

Plan-by-plan detail — levetiracetam 250 MG Tablet for Oral Suspension [Spritam]

Spritam has 2 products in the corpus; this table is for levetiracetam 250 MG Tablet for Oral Suspension [Spritam], the one carried on the most plans. The product table above covers every strength.

Plan	Contract	Tier	Prior auth	Step therapy	Qty limit
Anthem Dual Advantage (HMO D-SNP)	H5422-018	4	Yes	No	Yes
Anthem Extra Help (HMO-POS)	H5422-013	4	Yes	No	Yes
Anthem Full Dual Advantage (HMO D-SNP)	H5422-019	4	Yes	No	Yes
Anthem Full Dual Advantage Aligned (HMO D-SNP)	H4471-010	4	Yes	No	Yes
Anthem Full Dual Advantage Aligned (HMO D-SNP)	H4471-010	4	Yes	No	Yes
Anthem Full Dual Advantage Aligned (HMO D-SNP)	H4471-011	4	Yes	No	Yes
Anthem I CareMore Chronic Care (HMO-POS C-SNP)	H0544-004	4	Yes	No	Yes
Anthem I CareMore Chronic Care (HMO-POS C-SNP)	H0544-010	4	Yes	No	Yes
Anthem I CareMore Chronic Care 2 (HMO-POS C-SNP)	H4161-014	4	Yes	No	Yes
Anthem I CareMore Chronic Care 2 (HMO-POS C-SNP)	H4161-015	4	Yes	No	Yes
Anthem I CareMore Home Care (HMO I-SNP)	H0544-005	4	Yes	No	Yes
Anthem I CareMore Kidney Care (HMO-POS C-SNP)	H0544-015	4	Yes	No	Yes
Anthem I CareMore Kidney Care (HMO-POS C-SNP)	H0544-020	4	Yes	No	Yes
Anthem I CareMore Lung Care (HMO-POS C-SNP)	H0544-014	4	Yes	No	Yes
Anthem I CareMore Lung Care (HMO-POS C-SNP)	H0544-019	4	Yes	No	Yes
Anthem I CareMore Lung Care 2 (HMO-POS C-SNP)	H4161-016	4	Yes	No	Yes
Anthem I CareMore Lung Care 2 (HMO-POS C-SNP)	H4161-017	4	Yes	No	Yes
Anthem I CareMore Medicare Advantage (HMO-POS)	H4161-011	4	Yes	No	Yes
Anthem I CareMore Medicare Advantage (HMO-POS)	H4161-013	4	Yes	No	Yes
Anthem I CareMore Medicare Advantage 2 (HMO-POS)	H0544-002	4	Yes	No	Yes
Anthem I CareMore Premium Savings (HMO-POS)	H4161-012	4	Yes	No	Yes
Anthem Kidney Care (HMO-POS C-SNP)	H5422-015	4	Yes	No	Yes
Anthem Medicare Advantage (HMO-POS)	H0544-056	4	Yes	No	Yes
Anthem Medicare Advantage (HMO-POS)	H0544-061	4	Yes	No	Yes
Anthem Medicare Advantage (HMO-POS)	H0544-062	4	Yes	No	Yes
Anthem Medicare Advantage (HMO-POS)	H0544-063	4	Yes	No	Yes
Anthem Medicare Advantage (HMO-POS)	H0544-064	4	Yes	No	Yes
Anthem Medicare Advantage (HMO-POS)	H0544-065	4	Yes	No	Yes
Anthem Medicare Advantage (HMO-POS)	H0544-095	4	Yes	No	Yes
Anthem Medicare Advantage (HMO-POS)	H0544-096	4	Yes	No	Yes
Anthem Medicare Advantage (HMO-POS)	H0544-108	4	Yes	No	Yes
Anthem Medicare Advantage (HMO-POS)	H5422-011	4	Yes	No	Yes
Anthem Prime (HMO-POS)	H4161-002	4	Yes	No	Yes
Anthem Prime (HMO-POS)	H4161-003	4	Yes	No	Yes
Anthem Prime (HMO-POS)	H4161-004	4	Yes	No	Yes
Anthem Prime (HMO-POS)	H4161-005	4	Yes	No	Yes
Anthem Prime (HMO-POS)	H4161-006	4	Yes	No	Yes
Anthem Prime (HMO-POS)	H4161-007	4	Yes	No	Yes
Anthem Prime (HMO-POS)	H4161-009	4	Yes	No	Yes
Anthem Prime (HMO-POS)	H4161-010	4	Yes	No	Yes
Anthem Select (HMO-POS)	H0544-058	4	Yes	No	Yes
Anthem Select (HMO-POS)	H0544-066	4	Yes	No	Yes
Anthem Select (HMO-POS)	H0544-069	4	Yes	No	Yes
Anthem Select (HMO-POS)	H0544-091	4	Yes	No	Yes
Anthem Select (HMO-POS)	H0544-098	4	Yes	No	Yes
Blue Advantage Choice (PPO)	H0104-016	4	No	No	No
Blue Advantage Complete (PPO)	H0104-012	4	No	No	No
Blue Advantage Complete (PPO)	H0104-014	4	No	No	No
Blue Advantage Premier (PPO)	H0104-015	4	No	No	No
Blue Cross Medicare Advantage Choice (PPO)	H5959-009	4	No	No	No
Blue Cross Medicare Advantage Choice (PPO)	H5959-014	4	No	No	No
Blue Cross Medicare Advantage Choice (PPO)	H5959-014	4	No	No	No
Blue Cross Medicare Advantage Comfort (PPO)	H5959-015	4	No	No	No
Blue Cross Medicare Advantage Comfort (PPO)	H5959-016	4	No	No	No
Blue Cross Medicare Advantage Complete (PPO)	H5959-010	4	No	No	No
Blue Cross Medicare Advantage Complete (PPO)	H5959-010	4	No	No	No
Blue Cross Medicare Advantage Complete (PPO)	H5959-011	4	No	No	No
Blue Cross Medicare Advantage Core (PPO)	H5959-012	4	No	No	No
Blue Cross Medicare Advantage Core (PPO)	H5959-013	4	No	No	No
Blue Cross Medicare Advantage Core (PPO)	H5959-013	4	No	No	No
Blue Cross Medicare Advantage Secure (HMO)	H8547-001	4	No	No	No
Blue Medicare Advantage Classic PPO (PPO)	H5900-008	4	No	No	Yes
Blue Medicare Advantage Enhanced PPO (PPO)	H5900-004	4	No	No	Yes
Blue Medicare Advantage PPO (PPO)	H5900-001	4	No	No	Yes
Blue Medicare Choice (HMO)	H3449-026	4	No	No	No
Blue Medicare Enhanced (HMO-POS)	H3449-024	4	No	No	No
Blue Medicare Enhanced (HMO-POS)	H3449-024	4	No	No	No
Blue Medicare Enhanced (HMO-POS)	H3449-024	4	No	No	No
Blue Medicare Essential (HMO)	H3449-027	4	No	No	No
Blue Medicare Essential (HMO)	H3449-027	4	No	No	No
Blue Medicare Essential Plus (HMO-POS)	H3449-023	4	No	No	No
Blue Medicare Essential Plus (HMO-POS)	H3449-023	4	No	No	No
Blue Medicare Essential Plus (HMO-POS)	H3449-023	4	No	No	No
Blue Medicare Essential Plus (HMO-POS)	H3449-023	4	No	No	No
Blue Medicare PPO Enhanced (PPO)	H3404-003	4	No	No	No
Blue Medicare PPO Enhanced (PPO)	H3404-003	4	No	No	No
Blue Medicare Rx Enhanced (PDP)	S5540-004	4	No	No	No
Blue Medicare Rx Standard (PDP)	S5540-002	4	No	No	No
Blue MedicareRx Essentials (PDP)	S5726-020	4	No	No	No
Blue MedicareRx Plus (PDP)	S5726-014	4	No	No	No
Blue MedicareRx Value (PDP)	S5726-013	4	No	No	No
BlueCHiP for Medicare Access (HMO-POS)	H4152-022	4	No	No	No
BlueCHiP for Medicare Enhanced (HMO-POS)	H4152-013	4	No	No	No
BlueCHiP for Medicare Essential (HMO-POS)	H4152-023	4	No	No	No
BlueCHiP for Medicare Extra (HMO-POS)	H4152-018	4	No	No	No
BlueMedicare Complete Rx (PDP)	S5904-002	4	No	No	No
BlueMedicare Premier Rx (PDP)	S5904-001	4	No	No	No
BlueMedicare Select (PPO)	H5434-002	4	No	No	No
BlueMedicare Select (PPO)	H5434-045	4	No	No	No
BlueMedicare Value (PPO)	H5434-023	4	No	No	No
BlueMedicare Value (PPO)	H5434-024	4	No	No	No
BlueMedicare Value (PPO)	H5434-025	4	No	No	No
BlueMedicare Value (PPO)	H5434-026	4	No	No	No
BlueMedicare Value (PPO)	H5434-030	4	No	No	No
BlueMedicare Value (PPO)	H5434-031	4	No	No	No
BlueMedicare Value (PPO)	H5434-034	4	No	No	No
BlueMedicare Value (PPO)	H5434-035	4	No	No	No
BlueMedicare Value (PPO)	H5434-036	4	No	No	No
BlueRI for Duals (HMO D-SNP)	H4152-021	4	No	No	No
BlueRx Enhanced Plus (PDP)	S1030-001	4	No	No	No

Showing 100 of 269 covering plans.

Source

Monthly Prescription Drug Plan Formulary and Pharmacy Network Information — Basic Drugs Formulary File

Effective: 2026-06-30
Retrieved: 2026-07-19
SHA-256: e626e6bcda1aa6a0071e6f0df6bafe686ae41842cdf0a9feffdc649b6d3ff3ae

We publish the hash of the exact file we ingested so any answer can be audited against the bytes CMS served that day.

Spritam at other payers

Or see Spritam across every payer at once.

Administrative information only. Benefily reports what a payer has published in its own prior-authorization policy as of the effective date shown. It is not medical advice, not a coverage or payment guarantee, and not an authorization. Requirements vary by plan, place of service and member benefits — always verify with the payer before rendering service.