Antiepileptics (oral & rectal)

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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 but eligible patients will encounter a co-pay at the pharmacy.
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 CARBAMAZEPINE ORAL SUSP Y    
CARBAMAZEPINE TEGRETOL ORAL SUSP Y    
CARBAMAZEPINE CARBAMAZEPINE TAB CHEW Y    
CARBAMAZEPINE TEGRETOL XR TAB ER 12H Y    
CARBAMAZEPINE CARBAMAZEPINE ER TAB ER 12H Y    
CARBAMAZEPINE CARBAMAZEPINE TABLET Y    
CARBAMAZEPINE EPITOL TABLET Y    
CARBAMAZEPINE TEGRETOL TABLET Y    
DIAZEPAM DIASTAT KIT Y    
DIAZEPAM DIASTAT ACUDIAL KIT 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 DIVALPROEX SODIUM TABLET DR Y    
DIVALPROEX SODIUM DEPAKOTE TABLET DR Y    
ETHOSUXIMIDE ETHOSUXIMIDE CAPSULE Y    
ETHOSUXIMIDE ZARONTIN CAPSULE Y    
ETHOSUXIMIDE ETHOSUXIMIDE SOLUTION Y    
ETHOSUXIMIDE ZARONTIN SOLUTION Y    
ETHOTOIN PEGANONE TABLET Y    
GABAPENTIN GABAPENTIN CAPSULE Y    
GABAPENTIN NEURONTIN CAPSULE Y    
GABAPENTIN NEURONTIN TABLET Y    
GABAPENTIN GABAPENTIN TABLET Y    
LACOSAMIDE VIMPAT TABLET Y    
LAMOTRIGINE LAMOTRIGINE TABLET Y    
LAMOTRIGINE LAMICTAL TABLET Y    
LEVETIRACETAM LEVETIRACETAM SOLUTION Y    
LEVETIRACETAM KEPPRA SOLUTION Y    
LEVETIRACETAM LEVETIRACETAM TABLET Y    
LEVETIRACETAM KEPPRA TABLET Y    
LEVETIRACETAM ROWEEPRA TABLET Y    
METHSUXIMIDE CELONTIN CAPSULE Y    
OXCARBAZEPINE TRILEPTAL ORAL SUSP Y    
OXCARBAZEPINE OXCARBAZEPINE ORAL SUSP Y    
OXCARBAZEPINE TRILEPTAL TABLET Y    
OXCARBAZEPINE OXCARBAZEPINE TABLET Y    
PHENOBARBITAL PHENOBARBITAL ELIXIR Y    
PHENOBARBITAL PHENOBARBITAL TABLET Y    
PHENYTOIN PHENYTOIN ORAL SUSP Y    
PHENYTOIN DILANTIN-125 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 PRIMIDONE TABLET Y    
PRIMIDONE MYSOLINE TABLET Y    
RUFINAMIDE BANZEL TABLET Y    
TIAGABINE HCL TIAGABINE HCL TABLET Y    
TIAGABINE HCL GABITRIL TABLET Y    
TOPIRAMATE TOPIRAMATE TABLET Y    
TOPIRAMATE TOPAMAX TABLET Y    
VALPROIC ACID VALPROIC ACID CAPSULE Y    
VALPROIC ACID DEPAKENE CAPSULE Y    
VALPROIC ACID (AS SODIUM SALT) DEPAKENE SOLUTION Y    
VALPROIC ACID (AS SODIUM SALT) VALPROIC ACID SOLUTION Y    
ZONISAMIDE ZONISAMIDE CAPSULE Y    
ZONISAMIDE ZONEGRAN CAPSULE Y    
LAMOTRIGINE LAMICTAL (BLUE) TAB DS PK V    
LAMOTRIGINE LAMICTAL (GREEN) TAB DS PK V    
LAMOTRIGINE LAMICTAL (ORANGE) 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 LAMOTRIGINE TB CHW DSP V    
LAMOTRIGINE LAMICTAL 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 LAMICTAL ODT (ORANGE) TB RD DSPK V    
LAMOTRIGINE LAMICTAL ODT (BLUE) TB RD DSPK V    
LAMOTRIGINE LAMICTAL ODT (GREEN) TB RD 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    
BRIVARACETAM BRIVIACT SOLUTION N   Jul 28, 2016
BRIVARACETAM BRIVIACT TABLET N   Jul 28, 2016
CARBAMAZEPINE CARBAMAZEPINE ER CPMP 12HR N    
CARBAMAZEPINE CARBATROL CPMP 12HR N    
CLOBAZAM ONFI ORAL SUSP N PA Document  
CLOBAZAM ONFI TABLET N PA Document May 31, 2012
ESLICARBAZEPINE ACETATE APTIOM TABLET N    
FELBAMATE FELBATOL ORAL SUSP N    
FELBAMATE FELBAMATE ORAL SUSP N    
FELBAMATE FELBAMATE TABLET N    
FELBAMATE FELBATOL TABLET N    
GABAPENTIN GABAPENTIN SOLUTION N    
GABAPENTIN NEURONTIN SOLUTION N    
GABAPENTIN GRALISE TAB ER 24H N PA Document  
GABAPENTIN ENACARBIL HORIZANT TABLET ER N    
LACOSAMIDE VIMPAT SOLUTION 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    
PREGABALIN LYRICA CAPSULE N PA Document  
PREGABALIN LYRICA SOLUTION N PA Document  
RUFINAMIDE BANZEL ORAL SUSP N    
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 TOPIRAMATE CAP SPRINK N PA Document  
TOPIRAMATE TOPAMAX CAP SPRINK N PA Document  
VIGABATRIN SABRIL POWD PACK N    
VIGABATRIN SABRIL TABLET N