Antiepileptics, Outpatient
PDL Reference Documents
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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| carbamazepine | CARBAMAZEPINE | TAB CHEW | Y | N | Oct 01, 2020 | |
| carbamazepine | CARBAMAZEPINE ER | TAB ER 12H | Y | N | Oct 01, 2020 | |
| carbamazepine | TEGRETOL XR | TAB ER 12H | Y | N | Oct 01, 2020 | |
| carbamazepine | CARBAMAZEPINE | TABLET | Y | N | Oct 01, 2020 | |
| carbamazepine | EPITOL | TABLET | Y | N | Oct 01, 2020 | |
| carbamazepine | TEGRETOL | TABLET | Y | N | Oct 01, 2020 | |
| clobazam | ONFI | ORAL SUSP | Y | N | ||
| clobazam | CLOBAZAM | ORAL SUSP | Y | N | ||
| clobazam | ONFI | TABLET | Y | N | May 31, 2012 | |
| clobazam | CLOBAZAM | TABLET | Y | N | ||
| diazepam | DIAZEPAM | KIT | Y | N | ||
| diazepam | VALTOCO | SPRAY | Y | N | ||
| divalproex sodium | DIVALPROEX SODIUM | CAP DR SPR | Y | Y | Oct 01, 2020 | |
| divalproex sodium | DEPAKOTE SPRINKLE | CAP DR SPR | Y | Y | Oct 01, 2020 | |
| divalproex sodium | DIVALPROEX SODIUM ER | TAB ER 24H | Y | Y | Oct 01, 2020 | |
| divalproex sodium | DEPAKOTE ER | TAB ER 24H | Y | Y | Oct 01, 2020 | |
| divalproex sodium | DEPAKOTE | TABLET DR | Y | Y | Oct 01, 2020 | |
| divalproex sodium | DIVALPROEX SODIUM | TABLET DR | Y | Y | Oct 01, 2020 | |
| ethosuximide | ETHOSUXIMIDE | CAPSULE | Y | N | ||
| ethosuximide | ZARONTIN | CAPSULE | Y | N | ||
| ethosuximide | ETHOSUXIMIDE | SOLUTION | Y | N | ||
| ethosuximide | ZARONTIN | SOLUTION | Y | N | ||
| gabapentin | NEURONTIN | CAPSULE | Y | N | ||
| gabapentin | GABAPENTIN | CAPSULE | Y | N | ||
| gabapentin | GABAPENTIN | TABLET | Y | N | ||
| gabapentin | NEURONTIN | TABLET | Y | N | ||
| lacosamide | VIMPAT | TABLET | Y | N | ||
| lacosamide | LACOSAMIDE | TABLET | Y | N | ||
| lamotrigine | SUBVENITE | TABLET | Y | Y | Oct 01, 2020 | |
| lamotrigine | LAMICTAL | TABLET | Y | Y | Oct 01, 2020 | |
| lamotrigine | LAMOTRIGINE | TABLET | Y | Y | Oct 01, 2020 | |
| levetiracetam | KEPPRA | SOLUTION | Y | N | ||
| levetiracetam | LEVETIRACETAM | SOLUTION | Y | N | ||
| levetiracetam | KEPPRA XR | TAB ER 24H | Y | N | ||
| levetiracetam | LEVETIRACETAM ER | TAB ER 24H | Y | N | ||
| levetiracetam | KEPPRA | TABLET | Y | N | ||
| levetiracetam | LEVETIRACETAM | TABLET | Y | N | ||
| levetiracetam | ROWEEPRA | TABLET | Y | N | ||
| methsuximide | METHSUXIMIDE | CAPSULE | Y | N | ||
| methsuximide | CELONTIN | CAPSULE | Y | N | ||
| midazolam | NAYZILAM | SPRAY | Y | N | ||
| oxcarbazepine | OXCARBAZEPINE | ORAL SUSP | Y | N | ||
| oxcarbazepine | TRILEPTAL | ORAL SUSP | Y | N | ||
| oxcarbazepine | OXCARBAZEPINE | TABLET | Y | N | ||
| oxcarbazepine | TRILEPTAL | TABLET | Y | N | ||
| phenobarbital | PHENOBARBITAL | ELIXIR | Y | N | ||
| phenobarbital | PHENOBARBITAL | TABLET | Y | N | ||
| phenytoin | PHENYTOIN | ORAL SUSP | Y | N | ||
| phenytoin | DILANTIN-125 | ORAL SUSP | Y | N | ||
| phenytoin | PHENYTOIN | TAB CHEW | Y | N | ||
| phenytoin | DILANTIN | TAB CHEW | Y | N | ||
| phenytoin sodium extended | DILANTIN | CAPSULE | Y | N | ||
| phenytoin sodium extended | PHENYTEK | CAPSULE | Y | N | ||
| phenytoin sodium extended | PHENYTOIN SODIUM EXTENDED | CAPSULE | Y | N | ||
| pregabalin | LYRICA | CAPSULE | Y | Pharmacy PA | N | |
| pregabalin | PREGABALIN | CAPSULE | Y | Pharmacy PA | N | |
| primidone | PRIMIDONE | TABLET | Y | N | ||
| rufinamide | RUFINAMIDE | TABLET | Y | N | ||
| rufinamide | BANZEL | TABLET | Y | N | ||
| tiagabine HCl | TIAGABINE HCL | TABLET | Y | N | ||
| topiramate | TOPIRAMATE | TABLET | Y | N | ||
| topiramate | TOPAMAX | TABLET | Y | N | ||
| valproic acid | VALPROIC ACID | CAPSULE | Y | Y | ||
| valproic acid (as sodium salt) | VALPROIC ACID | SOLUTION | Y | Y | ||
| zonisamide | ZONISAMIDE | CAPSULE | Y | N | ||
| carbamazepine | EQUETRO | CPMP 12HR | V | Y | Oct 01, 2020 | |
| ganaxolone | ZTALMY | ORAL SUSP | V | Pharmacy PA | Y | |
| lamotrigine | SUBVENITE | ORAL SUSP | V | Y | Oct 01, 2020 | |
| lamotrigine | SUBVENITE (BLUE) | TAB DS PK | V | Y | Oct 01, 2020 | |
| lamotrigine | SUBVENITE (GREEN) | TAB DS PK | V | Y | Oct 01, 2020 | |
| lamotrigine | SUBVENITE (ORANGE) | TAB DS PK | V | Y | Oct 01, 2020 | |
| lamotrigine | LAMICTAL (BLUE) | TAB DS PK | V | Y | Oct 01, 2020 | |
| lamotrigine | LAMICTAL (ORANGE) | TAB DS PK | V | Y | Oct 01, 2020 | |
| lamotrigine | LAMICTAL (GREEN) | TAB DS PK | V | Y | Oct 01, 2020 | |
| lamotrigine | LAMOTRIGINE (BLUE) | TAB DS PK | V | Y | Oct 01, 2020 | |
| lamotrigine | LAMOTRIGINE (GREEN) | TAB DS PK | V | Y | Oct 01, 2020 | |
| lamotrigine | LAMOTRIGINE (ORANGE) | TAB DS PK | V | Y | Oct 01, 2020 | |
| lamotrigine | LAMOTRIGINE ER | TAB ER 24 | V | Y | Oct 01, 2020 | |
| lamotrigine | LAMICTAL XR | TAB ER 24 | V | Y | Oct 01, 2020 | |
| lamotrigine | LAMOTRIGINE ODT | TAB RAPDIS | V | Y | Oct 01, 2020 | |
| lamotrigine | LAMICTAL ODT | TAB RAPDIS | V | Y | Oct 01, 2020 | |
| lamotrigine | LAMICTAL | TB CHW DSP | V | Y | Oct 01, 2020 | |
| lamotrigine | LAMOTRIGINE | TB CHW DSP | V | Y | Oct 01, 2020 | |
| lamotrigine | LAMICTAL XR (BLUE) | TB ER DSPK | V | Y | Oct 01, 2020 | |
| lamotrigine | LAMICTAL XR (GREEN) | TB ER DSPK | V | Y | Oct 01, 2020 | |
| lamotrigine | LAMICTAL XR (ORANGE) | TB ER DSPK | V | Y | Oct 01, 2020 | |
| lamotrigine | LAMOTRIGINE ODT (BLUE) | TB RD DSPK | V | Y | Oct 01, 2020 | |
| lamotrigine | LAMOTRIGINE ODT (GREEN) | TB RD DSPK | V | Y | Oct 01, 2020 | |
| lamotrigine | LAMOTRIGINE ODT (ORANGE) | TB RD DSPK | V | Y | Oct 01, 2020 | |
| lamotrigine | LAMICTAL ODT (BLUE) | TB RD DSPK | V | Y | Oct 01, 2020 | |
| lamotrigine | LAMICTAL ODT (GREEN) | TB RD DSPK | V | Y | Oct 01, 2020 | |
| lamotrigine | LAMICTAL ODT (ORANGE) | TB RD DSPK | V | Y | Oct 01, 2020 | |
| brivaracetam | BRIVIACT | SOLUTION | N | N | Jul 28, 2016 | |
| brivaracetam | BRIVIACT | TABLET | N | N | Jul 28, 2016 | |
| cannabidiol (CBD) | EPIDIOLEX | SOLUTION | N | Pharmacy PA | N | |
| carbamazepine | CARBATROL | CPMP 12HR | N | N | Oct 01, 2020 | |
| carbamazepine | CARBAMAZEPINE ER | CPMP 12HR | N | N | Oct 01, 2020 | |
| carbamazepine | TEGRETOL | ORAL SUSP | N | N | Oct 01, 2020 | |
| carbamazepine | CARBAMAZEPINE | ORAL SUSP | N | N | Oct 01, 2020 | |
| carbamazepine | CARBAMAZEPINE | TAB CHEW | N | N | Oct 01, 2020 | |
| cenobamate | XCOPRI | TAB DS PK | N | N | ||
| cenobamate | XCOPRI | TABLET | N | N | ||
| clobazam | SYMPAZAN | FILM | N | N | ||
| clobazam | CLOBAZAM | SYRINGE | N | N | ||
| diazepam | LIBERVANT | FILM | N | N | ||
| eslicarbazepine acetate | APTIOM | TABLET | N | N | ||
| eslicarbazepine acetate | ESLICARBAZEPINE ACETATE | TABLET | N | N | ||
| felbamate | FELBATOL | ORAL SUSP | N | N | ||
| felbamate | FELBAMATE | ORAL SUSP | N | N | ||
| felbamate | FELBAMATE | TABLET | N | N | ||
| felbamate | FELBATOL | TABLET | N | N | ||
| fenfluramine HCl | FINTEPLA | SOLUTION | N | Pharmacy PA | N | |
| gabapentin | GABAPENTIN | SOLUTION | N | N | ||
| gabapentin | NEURONTIN | SOLUTION | N | N | ||
| gabapentin | GABAPENTIN ER | TAB ER 24H | N | N | ||
| gabapentin | GRALISE | TAB ER 24H | N | N | ||
| gabapentin | GRALISE | TAB24HDSPK | N | N | ||
| gabapentin | GABARONE | TABLET | N | N | ||
| gabapentin enacarbil | HORIZANT | TABLET ER | N | N | ||
| lacosamide | MOTPOLY XR | CAP ER 24H | N | N | ||
| lacosamide | VIMPAT | SOLUTION | N | N | ||
| lacosamide | LACOSAMIDE | SOLUTION | N | N | ||
| lacosamide | VIMPAT | TAB DS PK | N | N | ||
| levetiracetam | ELEPSIA XR | TAB ER 24H | N | N | ||
| levetiracetam | LEVETIRACETAM | TAB SUSP | N | N | ||
| levetiracetam | SPRITAM | TAB SUSP | N | N | ||
| oxcarbazepine | OXTELLAR XR | TAB ER 24H | N | N | ||
| oxcarbazepine | OXCARBAZEPINE ER | TAB ER 24H | N | N | ||
| perampanel | FYCOMPA | ORAL SUSP | N | N | ||
| perampanel | FYCOMPA | TABLET | N | N | ||
| perampanel | PERAMPANEL | TABLET | N | N | ||
| phenobarbital | PHENOBARBITAL | ELIXIR | N | N | ||
| pregabalin | LYRICA | SOLUTION | N | Pharmacy PA | N | |
| pregabalin | PREGABALIN | SOLUTION | N | Pharmacy PA | N | |
| pregabalin | LYRICA CR | TAB ER 24H | N | Pharmacy PA | N | |
| pregabalin | PREGABALIN ER | TAB ER 24H | N | Pharmacy PA | N | |
| primidone | PRIMIDONE | TABLET | N | N | ||
| rufinamide | BANZEL | ORAL SUSP | N | N | ||
| rufinamide | RUFINAMIDE | ORAL SUSP | N | N | ||
| stiripentol | DIACOMIT | CAPSULE | N | Pharmacy PA | N | |
| stiripentol | DIACOMIT | POWD PACK | N | Pharmacy PA | N | |
| topiramate | TOPIRAMATE ER | CAP ER 24H | N | Pharmacy PA | N | |
| topiramate | TROKENDI XR | CAP ER 24H | N | Pharmacy PA | N | |
| topiramate | TOPIRAMATE ER SPRINKLE | CAP SPR 24 | N | Pharmacy PA | N | |
| topiramate | QUDEXY XR | CAP SPR 24 | N | Pharmacy PA | N | |
| topiramate | TOPIRAMATE | CAP SPRINK | N | Pharmacy PA | N | |
| topiramate | TOPAMAX | CAP SPRINK | N | Pharmacy PA | N | |
| topiramate | TOPIRAMATE | SOLUTION | N | Pharmacy PA | N | |
| topiramate | EPRONTIA | SOLUTION | N | Pharmacy PA | N | |
| vigabatrin | SABRIL | POWD PACK | N | N | ||
| vigabatrin | VIGABATRIN | POWD PACK | N | N | ||
| vigabatrin | VIGADRONE | POWD PACK | N | N | ||
| vigabatrin | VIGPODER | POWD PACK | N | N | ||
| vigabatrin | VIGAFYDE | SOLUTION | N | N | ||
| vigabatrin | VIGABATRIN | TABLET | N | N | ||
| vigabatrin | VIGADRONE | TABLET | N | N | ||
| vigabatrin | SABRIL | TABLET | N | N | ||
| zonisamide | ZONISADE | ORAL SUSP | N | N | ||
| brivaracetam | BRIVARACETAM | TABLET | N | |||
| pregabalin | PREGABALIN | CAPSULE | Pharmacy PA | N |