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.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| brivaracetam | BRIVARACETAM | VIAL | N | |||
| brivaracetam | BRIVIACT | VIAL | N | Jul 28, 2016 | ||
| gabapentin/lidocaine/menthol | ACTIVE-PAC | KIT GEL-CP | N | |||
| carbamazepine | CARBAMAZEPINE ER | TAB ER 12H | Oct 01, 2020 | |||
| fosphenytoin sodium | FOSPHENYTOIN SODIUM | VIAL | ||||
| fosphenytoin sodium | CEREBYX | VIAL | ||||
| lacosamide | LACOSAMIDE | VIAL | ||||
| lacosamide | VIMPAT | VIAL | ||||
| levetiracetam | LEVETIRACETAM | VIAL | ||||
| levetiracetam | KEPPRA | VIAL | ||||
| levetiracetam in NaCl (iso-os) | LEVETIRACETAM-NACL | PIGGYBACK | ||||
| oxcarbazepine | OXCARBAZEPINE | TABLET | ||||
| phenytoin sodium | PHENYTOIN SODIUM | VIAL | ||||
| valproic acid (as sodium salt) | VALPROATE SODIUM | VIAL | BILL FFS |