Antiepileptics, Outpatient
PDL Reference Documents
- Antiepileptics, Outpatient - Oct 06, 2022
- Antiepileptics (non-injectable) - Oct 07, 2021
- Antiepileptics (non-injectable) - Oct 01, 2020
- Antiepileptics Class Update - Jun 04, 2020
- Antiepileptics Class Update - Jan 24, 2019
- Fibromyalgia Indication Review - Jan 24, 2019
- Neuropathic Pain - Jul 26, 2018
- Antiepileptics - Mar 22, 2018
- Nonanalgesics for Pain Class Update - Mar 23, 2017
- Antiepileptics - Jul 28, 2016
- Antiepileptics Literature Scan - Mar 26, 2015
- Antiepileptic Class Update and New Drug Evaluation - May 29, 2014
- DERP Drug Class Review Executive Summary: Neuropathic Pain - Feb 23, 2012
Drug Use Review Documents
Newsletters
PDL Status Values
Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the
Non-Preferred Drugs in Select PDL Classes prior authorization criteria.
New drugs will be listed as N until reviewed by the P&T Committee and are subject to the
New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.
To request a Prior Authorization, please use this form.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | New Drug Evaluation |
|---|---|---|---|---|---|
| carbamazepine | TEGRETOL | ORAL SUSP | Y | ||
| carbamazepine | CARBAMAZEPINE | ORAL SUSP | Y | ||
| carbamazepine | CARBAMAZEPINE | TAB CHEW | Y | ||
| carbamazepine | CARBAMAZEPINE ER | TAB ER 12H | Y | ||
| carbamazepine | TEGRETOL XR | TAB ER 12H | Y | ||
| carbamazepine | TEGRETOL | TABLET | Y | ||
| carbamazepine | EPITOL | TABLET | Y | ||
| carbamazepine | CARBAMAZEPINE | TABLET | Y | ||
| diazepam | DIAZEPAM | KIT | Y | ||
| diazepam | DIASTAT ACUDIAL | KIT | Y | ||
| diazepam | VALTOCO | SPRAY | Y | ||
| divalproex sodium | DEPAKOTE SPRINKLE | CAP DR SPR | Y | ||
| divalproex sodium | DIVALPROEX SODIUM | CAP DR SPR | Y | ||
| divalproex sodium | DEPAKOTE ER | TAB ER 24H | Y | ||
| divalproex sodium | DIVALPROEX SODIUM ER | TAB ER 24H | Y | ||
| divalproex sodium | DEPAKOTE | TABLET DR | Y | ||
| divalproex sodium | DIVALPROEX SODIUM | TABLET DR | Y | ||
| ethosuximide | ETHOSUXIMIDE | CAPSULE | Y | ||
| ethosuximide | ZARONTIN | CAPSULE | Y | ||
| ethosuximide | ETHOSUXIMIDE | SOLUTION | Y | ||
| ethosuximide | ZARONTIN | SOLUTION | Y | ||
| gabapentin | NEURONTIN | CAPSULE | Y | ||
| gabapentin | GABAPENTIN | CAPSULE | Y | ||
| gabapentin | NEURONTIN | TABLET | Y | ||
| gabapentin | GABAPENTIN | TABLET | Y | ||
| lacosamide | LACOSAMIDE | TABLET | Y | ||
| lacosamide | VIMPAT | TABLET | Y | ||
| lamotrigine | SUBVENITE | TABLET | Y | ||
| lamotrigine | LAMICTAL | TABLET | Y | ||
| lamotrigine | LAMOTRIGINE | TABLET | Y | ||
| levetiracetam | KEPPRA | SOLUTION | Y | ||
| levetiracetam | LEVETIRACETAM | SOLUTION | Y | ||
| levetiracetam | LEVETIRACETAM | TABLET | Y | ||
| levetiracetam | KEPPRA | TABLET | Y | ||
| levetiracetam | ROWEEPRA | TABLET | Y | ||
| methsuximide | CELONTIN | CAPSULE | Y | ||
| methsuximide | METHSUXIMIDE | CAPSULE | Y | ||
| midazolam | NAYZILAM | SPRAY | Y | ||
| oxcarbazepine | TRILEPTAL | ORAL SUSP | Y | ||
| oxcarbazepine | OXCARBAZEPINE | ORAL SUSP | Y | ||
| oxcarbazepine | OXCARBAZEPINE | TABLET | Y | ||
| oxcarbazepine | TRILEPTAL | TABLET | Y | ||
| phenobarbital | PHENOBARBITAL | ELIXIR | Y | ||
| phenobarbital | PHENOBARBITAL | TABLET | Y | ||
| phenytoin | DILANTIN-125 | ORAL SUSP | Y | ||
| phenytoin | PHENYTOIN | ORAL SUSP | Y | ||
| phenytoin | DILANTIN | TAB CHEW | Y | ||
| phenytoin | PHENYTOIN | TAB CHEW | Y | ||
| phenytoin sodium extended | DILANTIN | CAPSULE | Y | ||
| phenytoin sodium extended | PHENYTEK | CAPSULE | Y | ||
| phenytoin sodium extended | PHENYTOIN SODIUM EXTENDED | CAPSULE | Y | ||
| primidone | MYSOLINE | TABLET | Y | ||
| primidone | PRIMIDONE | TABLET | Y | ||
| rufinamide | BANZEL | TABLET | Y | ||
| rufinamide | RUFINAMIDE | TABLET | Y | ||
| tiagabine HCl | TIAGABINE HCL | TABLET | Y | ||
| tiagabine HCl | GABITRIL | TABLET | Y | ||
| topiramate | TOPAMAX | TABLET | Y | ||
| topiramate | TOPIRAMATE | TABLET | Y | ||
| valproic acid | VALPROIC ACID | CAPSULE | Y | ||
| valproic acid (as sodium salt) | VALPROIC ACID | SOLUTION | Y | ||
| zonisamide | ZONISAMIDE | CAPSULE | Y | ||
| carbamazepine | EQUETRO | CPMP 12HR | V | ||
| ganaxolone | ZTALMY | ORAL SUSP | V | PA Document | |
| lamotrigine | SUBVENITE (BLUE) | TAB DS PK | V | ||
| lamotrigine | SUBVENITE (GREEN) | TAB DS PK | V | ||
| lamotrigine | SUBVENITE (ORANGE) | TAB DS PK | V | ||
| lamotrigine | LAMOTRIGINE (GREEN) | TAB DS PK | V | ||
| lamotrigine | LAMICTAL (BLUE) | TAB DS PK | V | ||
| lamotrigine | LAMICTAL (ORANGE) | TAB DS PK | V | ||
| lamotrigine | LAMOTRIGINE (ORANGE) | TAB DS PK | V | ||
| lamotrigine | LAMOTRIGINE (BLUE) | TAB DS PK | V | ||
| lamotrigine | LAMICTAL (GREEN) | TAB DS PK | V | ||
| lamotrigine | LAMOTRIGINE ER | TAB ER 24 | V | ||
| lamotrigine | LAMICTAL XR | TAB ER 24 | V | ||
| lamotrigine | LAMOTRIGINE ODT | TAB RAPDIS | V | ||
| lamotrigine | LAMICTAL ODT | TAB RAPDIS | V | ||
| lamotrigine | LAMICTAL | TB CHW DSP | V | ||
| lamotrigine | LAMOTRIGINE | TB CHW DSP | V | ||
| lamotrigine | LAMICTAL XR (BLUE) | TB ER DSPK | V | ||
| lamotrigine | LAMICTAL XR (GREEN) | TB ER DSPK | V | ||
| lamotrigine | LAMICTAL XR (ORANGE) | TB ER DSPK | V | ||
| lamotrigine | LAMOTRIGINE ODT (BLUE) | TB RD DSPK | V | ||
| lamotrigine | LAMOTRIGINE ODT (GREEN) | TB RD DSPK | V | ||
| lamotrigine | LAMOTRIGINE ODT (ORANGE) | TB RD DSPK | V | ||
| lamotrigine | LAMICTAL ODT (BLUE) | TB RD DSPK | V | ||
| lamotrigine | LAMICTAL ODT (GREEN) | TB RD DSPK | V | ||
| lamotrigine | LAMICTAL ODT (ORANGE) | TB RD DSPK | V | ||
| brivaracetam | BRIVIACT | SOLUTION | N | Jul 28, 2016 | |
| brivaracetam | BRIVIACT | TABLET | N | Jul 28, 2016 | |
| cannabidiol (CBD) | EPIDIOLEX | SOLUTION | N | PA Document | |
| carbamazepine | CARBATROL | CPMP 12HR | N | ||
| carbamazepine | CARBAMAZEPINE ER | CPMP 12HR | N | ||
| cenobamate | XCOPRI | TAB DS PK | N | ||
| cenobamate | XCOPRI | TABLET | N | ||
| clobazam | SYMPAZAN | FILM | N | PA Document | |
| clobazam | ONFI | ORAL SUSP | N | PA Document | |
| clobazam | CLOBAZAM | ORAL SUSP | N | PA Document | |
| clobazam | ONFI | TABLET | N | PA Document | May 31, 2012 |
| clobazam | CLOBAZAM | TABLET | N | PA Document | |
| eslicarbazepine acetate | APTIOM | TABLET | N | ||
| felbamate | FELBATOL | ORAL SUSP | N | ||
| felbamate | FELBAMATE | ORAL SUSP | N | ||
| felbamate | FELBATOL | TABLET | N | ||
| felbamate | FELBAMATE | TABLET | N | ||
| fenfluramine HCl | FINTEPLA | SOLUTION | N | PA Document | |
| gabapentin | NEURONTIN | SOLUTION | N | ||
| gabapentin | GABAPENTIN | SOLUTION | N | ||
| gabapentin | GRALISE | TAB ER 24H | N | ||
| gabapentin | GABAPENTIN ER | TAB ER 24H | N | ||
| gabapentin | GRALISE | TAB24HDSPK | N | ||
| gabapentin enacarbil | HORIZANT | TABLET ER | N | ||
| lacosamide | MOTPOLY XR | CAP ER 24H | N | ||
| lacosamide | LACOSAMIDE | SOLUTION | N | ||
| lacosamide | VIMPAT | SOLUTION | N | ||
| lacosamide | VIMPAT | TAB DS PK | N | ||
| levetiracetam | ELEPSIA XR | TAB ER 24H | N | ||
| levetiracetam | LEVETIRACETAM ER | TAB ER 24H | N | ||
| levetiracetam | KEPPRA XR | TAB ER 24H | N | ||
| levetiracetam | SPRITAM | TAB SUSP | N | ||
| oxcarbazepine | OXTELLAR XR | TAB ER 24H | N | ||
| perampanel | FYCOMPA | ORAL SUSP | N | ||
| perampanel | FYCOMPA | TABLET | N | ||
| phenobarbital | PHENOBARBITAL | ELIXIR | N | ||
| pregabalin | PREGABALIN | CAPSULE | N | PA Document | |
| pregabalin | LYRICA | CAPSULE | N | PA Document | |
| pregabalin | LYRICA | SOLUTION | N | PA Document | |
| pregabalin | PREGABALIN | SOLUTION | N | PA Document | |
| pregabalin | LYRICA CR | TAB ER 24H | N | PA Document | |
| pregabalin | PREGABALIN ER | TAB ER 24H | N | PA Document | |
| primidone | PRIMIDONE | TABLET | N | ||
| rufinamide | BANZEL | ORAL SUSP | N | ||
| rufinamide | RUFINAMIDE | ORAL SUSP | N | ||
| stiripentol | DIACOMIT | CAPSULE | N | PA Document | |
| stiripentol | DIACOMIT | POWD PACK | N | PA Document | |
| topiramate | TOPIRAMATE ER | CAP ER 24H | N | PA Document | |
| topiramate | TROKENDI XR | CAP ER 24H | N | PA Document | |
| topiramate | QUDEXY XR | CAP SPR 24 | N | PA Document | |
| topiramate | TOPIRAMATE ER | CAP SPR 24 | N | PA Document | |
| topiramate | TOPAMAX | CAP SPRINK | N | PA Document | |
| topiramate | TOPIRAMATE | CAP SPRINK | N | PA Document | |
| topiramate | EPRONTIA | SOLUTION | N | PA Document | |
| vigabatrin | SABRIL | POWD PACK | N | ||
| vigabatrin | VIGABATRIN | POWD PACK | N | ||
| vigabatrin | VIGADRONE | POWD PACK | N | ||
| vigabatrin | VIGPODER | POWD PACK | N | ||
| vigabatrin | SABRIL | TABLET | N | ||
| vigabatrin | VIGABATRIN | TABLET | N | ||
| vigabatrin | VIGADRONE | TABLET | N | ||
| zonisamide | ZONISADE | ORAL SUSP | N |