Antiepileptics, Parenteral

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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
brivaracetam BRIVIACT VIAL N   Jul 28, 2016
fosphenytoin sodium FOSPHENYTOIN SODIUM VIAL    
fosphenytoin sodium CEREBYX VIAL    
lacosamide VIMPAT VIAL    
levetiracetam LEVETIRACETAM VIAL    
levetiracetam KEPPRA VIAL    
levetiracetam in NaCl (iso-os) LEVETIRACETAM-NACL PIGGYBACK    
phenytoin sodium PHENYTOIN SODIUM AMPUL    
phenytoin sodium PHENYTOIN SODIUM SYRINGE    
phenytoin sodium PHENYTOIN SODIUM VIAL    
valproic acid (as sodium salt) VALPROATE SODIUM VIAL    
valproic acid (as sodium salt) DEPACON VIAL