Antiepileptics, Parenteral
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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 50474097063 | BRIVIACT | brivaracetam | VIAL | 50 mg/5 mL | N | Y | |
| 50474097075 | BRIVIACT | brivaracetam | VIAL | 50 mg/5 mL | N | Y | |
| 00069547101 | CEREBYX | fosphenytoin sodium | VIAL | 100 mg PE/2 mL | Y | ||
| 00069547102 | CEREBYX | fosphenytoin sodium | VIAL | 100 mg PE/2 mL | Y | ||
| 00069600102 | CEREBYX | fosphenytoin sodium | VIAL | 100 mg PE/2 mL | Y | ||
| 00069600125 | CEREBYX | fosphenytoin sodium | VIAL | 100 mg PE/2 mL | Y | ||
| 00641613601 | FOSPHENYTOIN SODIUM | fosphenytoin sodium | VIAL | 100 mg PE/2 mL | Y | ||
| 00641613625 | FOSPHENYTOIN SODIUM | fosphenytoin sodium | VIAL | 100 mg PE/2 mL | Y | ||
| 25021079802 | FOSPHENYTOIN SODIUM | fosphenytoin sodium | VIAL | 100 mg PE/2 mL | Y | ||
| 63323040301 | FOSPHENYTOIN SODIUM | fosphenytoin sodium | VIAL | 100 mg PE/2 mL | Y | ||
| 63323040302 | FOSPHENYTOIN SODIUM | fosphenytoin sodium | VIAL | 100 mg PE/2 mL | Y | ||
| 68462062102 | FOSPHENYTOIN SODIUM | fosphenytoin sodium | VIAL | 100 mg PE/2 mL | Y | ||
| 68462062154 | FOSPHENYTOIN SODIUM | fosphenytoin sodium | VIAL | 100 mg PE/2 mL | Y | ||
| 70121138101 | FOSPHENYTOIN SODIUM | fosphenytoin sodium | VIAL | 100 mg PE/2 mL | Y | ||
| 00069547401 | CEREBYX | fosphenytoin sodium | VIAL | 500 mg PE/10 mL | Y | ||
| 00069547402 | CEREBYX | fosphenytoin sodium | VIAL | 500 mg PE/10 mL | Y | ||
| 00069600110 | CEREBYX | fosphenytoin sodium | VIAL | 500 mg PE/10 mL | Y | ||
| 00069600121 | CEREBYX | fosphenytoin sodium | VIAL | 500 mg PE/10 mL | Y | ||
| 00641613701 | FOSPHENYTOIN SODIUM | fosphenytoin sodium | VIAL | 500 mg PE/10 mL | Y | ||
| 00641613710 | FOSPHENYTOIN SODIUM | fosphenytoin sodium | VIAL | 500 mg PE/10 mL | Y | ||
| 25021079810 | FOSPHENYTOIN SODIUM | fosphenytoin sodium | VIAL | 500 mg PE/10 mL | Y | ||
| 63323040304 | FOSPHENYTOIN SODIUM | fosphenytoin sodium | VIAL | 500 mg PE/10 mL | Y | ||
| 63323040310 | FOSPHENYTOIN SODIUM | fosphenytoin sodium | VIAL | 500 mg PE/10 mL | Y | ||
| 67457051710 | FOSPHENYTOIN SODIUM | fosphenytoin sodium | VIAL | 500 mg PE/10 mL | Y | ||
| 68462062210 | FOSPHENYTOIN SODIUM | fosphenytoin sodium | VIAL | 500 mg PE/10 mL | Y | ||
| 68462062264 | FOSPHENYTOIN SODIUM | fosphenytoin sodium | VIAL | 500 mg PE/10 mL | Y | ||
| 68462094510 | FOSPHENYTOIN SODIUM | fosphenytoin sodium | VIAL | 500 mg PE/10 mL | Y | ||
| 68462094564 | FOSPHENYTOIN SODIUM | fosphenytoin sodium | VIAL | 500 mg PE/10 mL | Y | ||
| 70121139001 | FOSPHENYTOIN SODIUM | fosphenytoin sodium | VIAL | 500 mg PE/10 mL | Y | ||
| 70121139007 | FOSPHENYTOIN SODIUM | fosphenytoin sodium | VIAL | 500 mg PE/10 mL | Y | ||
| 45861010801 | ACTIVE-PAC | gabapentin/lidocaine/menthol | KIT GEL-CP | 300 mg-4 %-1 % | N | Y | |
| 13811020740 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 13811020774 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 25021079120 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 31722020320 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 31722020331 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 31722020332 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 31722020333 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 43598008711 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 43598008758 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 60505623500 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 60505623504 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 65219020401 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 65219020420 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 69543045510 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 69543045520 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 70069047101 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 70069047110 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 70710135901 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 70710135906 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 70710188601 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 70710188606 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 72205022001 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 72205022007 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 72266024201 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 72266024205 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 72603026301 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 72603026302 | LACOSAMIDE | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 00131181067 | VIMPAT | lacosamide | VIAL | 200 mg/20 mL | Y | ||
| 50474000263 | KEPPRA | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 00143967301 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 00143967325 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 00409188602 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 00409188622 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 00409201105 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 00409201125 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 25021078005 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 43547045410 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 43547045441 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 55150017705 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 63323040001 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 63323040005 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 63323040041 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 63323040044 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 67457079000 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 67457079005 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 68094031301 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 68094031310 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 68094031325 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 72205012001 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 72205012007 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 72205012025 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 72485010601 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 72485010610 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 72485010625 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 72572036001 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 72572036025 | LEVETIRACETAM | levetiracetam | VIAL | 500 mg/5 mL | Y | ||
| 00264100990 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,000 mg/100 mL | Y | ||
| 14789022008 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,000 mg/100 mL | Y | ||
| 14789022010 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,000 mg/100 mL | Y | ||
| 25021079482 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,000 mg/100 mL | Y | ||
| 36000035601 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,000 mg/100 mL | Y | ||
| 36000035640 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,000 mg/100 mL | Y | ||
| 43598063610 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,000 mg/100 mL | Y | ||
| 43598063652 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,000 mg/100 mL | Y | ||
| 43598075710 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,000 mg/100 mL | Y | ||
| 43598075752 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,000 mg/100 mL | Y | ||
| 44567050201 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,000 mg/100 mL | Y | ||
| 44567050210 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,000 mg/100 mL | Y | ||
| 55150024747 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,000 mg/100 mL | Y | ||
| 65145017401 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,000 mg/100 mL | Y | ||
| 65145017410 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,000 mg/100 mL | Y | ||
| 67457026500 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,000 mg/100 mL | Y | ||
| 67457026510 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,000 mg/100 mL | Y | ||
| 70860060341 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,000 mg/100 mL | Y | ||
| 70860060382 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,000 mg/100 mL | Y | ||
| 00264150990 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,500 mg/100 mL | Y | ||
| 14789033008 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,500 mg/100 mL | Y | ||
| 14789033015 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,500 mg/100 mL | Y | ||
| 25021079582 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,500 mg/100 mL | Y | ||
| 36000035401 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,500 mg/100 mL | Y | ||
| 36000035440 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,500 mg/100 mL | Y | ||
| 43598063710 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,500 mg/100 mL | Y | ||
| 43598063752 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,500 mg/100 mL | Y | ||
| 43598075910 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,500 mg/100 mL | Y | ||
| 43598075952 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,500 mg/100 mL | Y | ||
| 44567050301 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,500 mg/100 mL | Y | ||
| 44567050310 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,500 mg/100 mL | Y | ||
| 55150024847 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,500 mg/100 mL | Y | ||
| 65145017501 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,500 mg/100 mL | Y | ||
| 65145017510 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,500 mg/100 mL | Y | ||
| 67457026600 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,500 mg/100 mL | Y | ||
| 67457026610 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,500 mg/100 mL | Y | ||
| 70860060441 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,500 mg/100 mL | Y | ||
| 70860060482 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 1,500 mg/100 mL | Y | ||
| 44567050001 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 250 mg/50 mL | Y | ||
| 44567050010 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 250 mg/50 mL | Y | ||
| 00264500990 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 500 mg/100 mL | Y | ||
| 14789011005 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 500 mg/100 mL | Y | ||
| 14789011008 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 500 mg/100 mL | Y | ||
| 25021079382 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 500 mg/100 mL | Y | ||
| 36000035201 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 500 mg/100 mL | Y | ||
| 36000035240 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 500 mg/100 mL | Y | ||
| 43598063510 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 500 mg/100 mL | Y | ||
| 43598063552 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 500 mg/100 mL | Y | ||
| 43598075510 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 500 mg/100 mL | Y | ||
| 43598075552 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 500 mg/100 mL | Y | ||
| 44567050101 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 500 mg/100 mL | Y | ||
| 44567050102 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 500 mg/100 mL | Y | ||
| 44567050110 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 500 mg/100 mL | Y | ||
| 44567050190 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 500 mg/100 mL | Y | ||
| 55150024647 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 500 mg/100 mL | Y | ||
| 65145017301 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 500 mg/100 mL | Y | ||
| 65145017310 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 500 mg/100 mL | Y | ||
| 67457025500 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 500 mg/100 mL | Y | ||
| 67457025510 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 500 mg/100 mL | Y | ||
| 70860060241 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 500 mg/100 mL | Y | ||
| 70860060282 | LEVETIRACETAM-NACL | levetiracetam in NaCl (iso-os) | PIGGYBACK | 500 mg/100 mL | Y | ||
| 00641049321 | PHENYTOIN SODIUM | phenytoin sodium | VIAL | 50 mg/mL | Y | ||
| 00641049325 | PHENYTOIN SODIUM | phenytoin sodium | VIAL | 50 mg/mL | Y | ||
| 00641255510 | PHENYTOIN SODIUM | phenytoin sodium | VIAL | 50 mg/mL | Y | ||
| 00641255541 | PHENYTOIN SODIUM | phenytoin sodium | VIAL | 50 mg/mL | Y | ||
| 00641613801 | PHENYTOIN SODIUM | phenytoin sodium | VIAL | 50 mg/mL | Y | ||
| 00641613825 | PHENYTOIN SODIUM | phenytoin sodium | VIAL | 50 mg/mL | Y | ||
| 00641613901 | PHENYTOIN SODIUM | phenytoin sodium | VIAL | 50 mg/mL | Y | ||
| 00641613910 | PHENYTOIN SODIUM | phenytoin sodium | VIAL | 50 mg/mL | Y | ||
| 42192061402 | PHENYTOIN SODIUM | phenytoin sodium | VIAL | 50 mg/mL | Y | ||
| 42192061405 | PHENYTOIN SODIUM | phenytoin sodium | VIAL | 50 mg/mL | Y | ||
| 42192061410 | PHENYTOIN SODIUM | phenytoin sodium | VIAL | 50 mg/mL | Y | ||
| 42192061430 | PHENYTOIN SODIUM | phenytoin sodium | VIAL | 50 mg/mL | Y | ||
| 00143963701 | VALPROATE SODIUM | valproic acid (as sodium salt) | VIAL | 500 mg/5 mL (100 mg/mL) | Y | ||
| 00143963710 | VALPROATE SODIUM | valproic acid (as sodium salt) | VIAL | 500 mg/5 mL (100 mg/mL) | Y | ||
| 00143978501 | VALPROATE SODIUM | valproic acid (as sodium salt) | VIAL | 500 mg/5 mL (100 mg/mL) | Y | ||
| 00143978510 | VALPROATE SODIUM | valproic acid (as sodium salt) | VIAL | 500 mg/5 mL (100 mg/mL) | Y | ||
| 25021079705 | VALPROATE SODIUM | valproic acid (as sodium salt) | VIAL | 500 mg/5 mL (100 mg/mL) | Y | ||
| 63323049401 | VALPROATE SODIUM | valproic acid (as sodium salt) | VIAL | 500 mg/5 mL (100 mg/mL) | Y | ||
| 63323049405 | VALPROATE SODIUM | valproic acid (as sodium salt) | VIAL | 500 mg/5 mL (100 mg/mL) | Y | ||
| 63323049416 | VALPROATE SODIUM | valproic acid (as sodium salt) | VIAL | 500 mg/5 mL (100 mg/mL) | Y | ||
| 63323049441 | VALPROATE SODIUM | valproic acid (as sodium salt) | VIAL | 500 mg/5 mL (100 mg/mL) | Y | ||
| 70860078405 | VALPROATE SODIUM | valproic acid (as sodium salt) | VIAL | 500 mg/5 mL (100 mg/mL) | Y | ||
| 70860078441 | VALPROATE SODIUM | valproic acid (as sodium salt) | VIAL | 500 mg/5 mL (100 mg/mL) | Y |