LA Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) Effective Date: July 1, 2024
Additional Point-of-Sale (POS) Edits May Apply Drugs highlighted in yellow indicate a new addition or a change in status Page | 6
Descriptive Therapeutic Class
Drugs on NPDL which Require Prior Authorization (PA)
ANTICONVULSANTS (8) Continued
Diazepam Rectal Device (AG; Diastat® AcuDial™)
Lacosamide Solution, Tablet (Vimpat®)
Divalproex DR Tablet (Generic)
Lamotrigine Dispersible Tablet, ODT, Tablet (Lamictal®)
Divalproex ER Tablet (Generic)
Lamotrigine ODT Titration Kit, Tablet Starter Kit (Generic; Lamictal®)
Divalproex Sodium DR Sprinkle (Generic; Depakote® Sprinkles)
Lamotrigine ER Tablet, Titration Kit (Lamictal® XR)
Eslicarbazepine Acetate Tablet (Aptiom®)
Levetiracetam ER Tablet (Keppra XR®)
Ethosuximide Capsule (AG; Generic)
Levetiracetam Tablet for Oral Suspension (Spritam®)
Ethosuximide Syrup (Generic)
Levetiracetam Solution, Tablet (Keppra®)
Felbamate Suspension (Generic)
Levetiracetam ER Tablet (Elepsia™ XR)
Felbamate Tablet (Generic; Felbatol®)
Oxcarbazepine Tablet (Trileptal®)
Lacosamide Solution, Tablet (Generic)
Phenytoin 100mg Capsule (Dilantin®)
Lamotrigine Dispersible Tablet, ER Tablet, ODT, Tablet (Generic)
Phenytoin Chewable Tablet (Dilantin® Infatabs®)
Levetiracetam ER Tablet, Solution, Tablet (Generic)
Phenytoin Sodium Capsule (Phenytek®)
Methsuximide Capsule (Celontin®)
Phenytoin Suspension (Dilantin®)
Midazolam Nasal Spray (Nayzilam®)
Primidone Tablet (Mysoline®)
Oxcarbazepine Suspension (Generic; Trileptal®)
Tiagabine Tablet (Generic; Gabitril®)
Oxcarbazepine Tablet (Generic)
Topiramate ER Capsule (Generic; Qudexy® XR)
Oxcarbazepine XR Tablet (Oxtellar XR®)
Topiramate Solution (Eprontia™)
Perampanel Suspension, Tablet (Fycompa®)
Topiramate Sprinkle, Tablet (Topamax®)
Phenobarbital Elixir, Tablet (Generic)
Zonisamide Suspension (Zonisade™)
Phenytoin 100mg Capsule (Generic)
Phenytoin 30 mg Capsule (Dilantin®)
Phenytoin Chewable Tablet (Generic)
Phenytoin Sodium Capsule (Generic for Phenytek®)
Phenytoin Suspension (AG; Generic)
Primidone Tablet (Generic)
Rufinamide Suspension, Tablet (Generic; Banzel®)
Stiripentol Capsule, Powder Pack (Diacomit®)
Topiramate ER Capsule (AG for Qudexy® XR)
Topiramate ER Capsule (Generic; Trokendi XR®)
Topiramate Sprinkle, Tablet (Generic)
Valproic Acid Capsule, Solution (Generic)
Vigabatrin Powder Pack, Tablet (Generic; Sabril®; Vigadrone®)
Zonisamide Capsule (Generic)