All *ANTICONVULSANTS*

Aptiom TABLET 200 MG ORAL
Aptiom TABLET 200 MG ORAL

Eslicarbazepine Acetate

Tier: 3
PA Type: No Prior Authorization
ST: N
Aptiom TABLET 400 MG ORAL
Aptiom TABLET 400 MG ORAL

Eslicarbazepine Acetate

Tier: 3
PA Type: No Prior Authorization
ST: N
Aptiom TABLET 600 MG ORAL
Aptiom TABLET 600 MG ORAL

Eslicarbazepine Acetate

Tier: 3
PA Type: No Prior Authorization
ST: N
Aptiom TABLET 800 MG ORAL
Aptiom TABLET 800 MG ORAL

Eslicarbazepine Acetate

Tier: 3
PA Type: No Prior Authorization
ST: N
Banzel Suspension 40 MG/ML Oral
Banzel Suspension 40 MG/ML Oral

Rufinamide

Tier: 3
PA Type: No Prior Authorization
ST: N
Banzel TABLET 200 MG ORAL
Banzel TABLET 200 MG ORAL

Rufinamide

Tier: 3
PA Type: No Prior Authorization
ST: N
Banzel TABLET 400 MG ORAL
Banzel TABLET 400 MG ORAL

Rufinamide

Tier: 3
PA Type: No Prior Authorization
ST: N
Briviact SOLUTION 10 MG/ML ORAL
Briviact SOLUTION 10 MG/ML ORAL

Brivaracetam

Tier: 3
PA Type: No Prior Authorization
ST: N
Briviact SOLUTION 50 MG/5ML Intravenous
Briviact SOLUTION 50 MG/5ML Intravenous

Brivaracetam

Tier: 3
PA Type: No Prior Authorization
ST: N
Briviact SOLUTION 50 MG/5ML Intravenous
Briviact SOLUTION 50 MG/5ML Intravenous

Brivaracetam

Tier: 3
PA Type: No Prior Authorization
ST: N
Briviact TABLET 10 MG ORAL
Briviact TABLET 10 MG ORAL

Brivaracetam

Tier: 3
PA Type: No Prior Authorization
ST: N
Briviact TABLET 100 MG ORAL
Briviact TABLET 100 MG ORAL

Brivaracetam

Tier: 3
PA Type: No Prior Authorization
ST: N