Antiepileptics (oral & rectal)

← Back to Class List

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 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 EPITOL TABLET Y    
carbamazepine TEGRETOL TABLET Y    
carbamazepine CARBAMAZEPINE TABLET Y    
diazepam DIASTAT ACUDIAL KIT Y    
diazepam DIAZEPAM KIT Y    
diazepam DIASTAT KIT Y    
divalproex sodium DIVALPROEX SODIUM CAP DR SPR Y    
divalproex sodium DEPAKOTE SPRINKLE CAP DR SPR Y    
divalproex sodium DIVALPROEX SODIUM ER TAB ER 24H Y    
divalproex sodium DEPAKOTE 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 NEURONTIN CAPSULE Y    
gabapentin GABAPENTIN 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 ROWEEPRA TABLET Y    
levetiracetam KEPPRA TABLET Y    
levetiracetam LEVETIRACETAM TABLET Y    
methsuximide CELONTIN CAPSULE 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 PHENYTOIN SODIUM EXTENDED CAPSULE Y    
phenytoin sodium extended PHENYTEK CAPSULE Y    
phenytoin sodium extended DILANTIN 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) VALPROIC ACID SOLUTION Y    
valproic acid (as sodium salt) DEPAKENE SOLUTION Y    
zonisamide ZONISAMIDE CAPSULE Y    
zonisamide ZONEGRAN CAPSULE Y    
lamotrigine LAMOTRIGINE (ORANGE) TAB DS PK V    
lamotrigine LAMOTRIGINE (GREEN) TAB DS PK V    
lamotrigine LAMOTRIGINE (BLUE) TAB DS PK V    
lamotrigine LAMOTRIGINE TAB DS PK V    
lamotrigine LAMICTAL (ORANGE) TAB DS PK V    
lamotrigine LAMICTAL (GREEN) TAB DS PK V    
lamotrigine LAMICTAL (BLUE) 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 (ORANGE) TB ER DSPK V    
lamotrigine LAMICTAL XR (GREEN) TB ER DSPK V    
lamotrigine LAMICTAL XR (BLUE) TB ER DSPK V    
lamotrigine LAMOTRIGINE ODT (ORANGE) TB RD DSPK V    
lamotrigine LAMOTRIGINE ODT (GREEN) TB RD DSPK V    
lamotrigine LAMOTRIGINE ODT (BLUE) TB RD DSPK V    
lamotrigine LAMICTAL ODT (ORANGE) TB RD DSPK V    
lamotrigine LAMICTAL ODT (GREEN) TB RD DSPK V    
lamotrigine LAMICTAL ODT (BLUE) TB RD DSPK V    
brivaracetam BRIVIACT SOLUTION N   Jul 28, 2016
brivaracetam BRIVIACT TABLET N   Jul 28, 2016
carbamazepine CARBATROL CPMP 12HR N    
carbamazepine CARBAMAZEPINE ER CPMP 12HR N    
clobazam ONFI ORAL SUSP N PA Document  
clobazam ONFI TABLET N PA Document May 31, 2012
diazepam DIAZEPAM SOLUTION N    
eslicarbazepine acetate APTIOM TABLET N    
felbamate FELBATOL ORAL SUSP N    
felbamate FELBAMATE ORAL SUSP N    
felbamate FELBATOL TABLET N    
felbamate FELBAMATE TABLET N    
gabapentin NEURONTIN SOLUTION N    
gabapentin GABAPENTIN SOLUTION N    
gabapentin GRALISE TAB ER 24H N PA Document  
gabapentin enacarbil HORIZANT TABLET ER N    
lacosamide VIMPAT SOLUTION N    
levetiracetam KEPPRA XR TAB ER 24H N    
levetiracetam LEVETIRACETAM ER 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 TOPIRAMATE ER CAP SPR 24 N PA Document  
topiramate QUDEXY XR CAP SPR 24 N PA Document  
topiramate TOPAMAX CAP SPRINK N PA Document  
topiramate TOPIRAMATE CAP SPRINK N PA Document  
vigabatrin VIGABATRIN POWD PACK N    
vigabatrin SABRIL POWD PACK N    
vigabatrin SABRIL TABLET N    
diazepam DIAZEPAM ORAL CONC    
diazepam DIAZEPAM SOLUTION    
diazepam DIAZEPAM SYRINGE    
diazepam DIAZEPAM TABLET    
diazepam DIAZEPAM VIAL