ANTICONVULSANTS | Vendor Drug Program

Brand Name/Generic Name	NDC/Manufacturer	FFS Clinical Prior Auth Required	PDL Prior Auth Required	Programs
APTIOM 200 MG TABLET eslicarbazepine acetate	63402020230 SUNOVION-SUMITO	No	No	Medicaid CHIP CSHCN
APTIOM 400 MG TABLET eslicarbazepine acetate	63402020430 SUNOVION-SUMITO	No	No	Medicaid CHIP CSHCN
APTIOM 600 MG TABLET eslicarbazepine acetate	63402020660 SUNOVION-SUMITO	No	No	Medicaid CHIP CSHCN
APTIOM 800 MG TABLET eslicarbazepine acetate	63402020830 SUNOVION-SUMITO	No	No	Medicaid CHIP CSHCN
BANZEL 200 MG TABLET rufinamide	62856058252 EISAI INC.	No	No	Medicaid CHIP CSHCN
BANZEL 40 MG/ML SUSPENSION rufinamide	62856058446 EISAI INC.	No	No	Medicaid CHIP CSHCN
BANZEL 400 MG TABLET rufinamide	62856058352 EISAI INC.	No	No	Medicaid CHIP CSHCN
BRIVIACT 10 MG TABLET brivaracetam	50474037066 UCB PHARMA	No	No	Medicaid CHIP CSHCN
BRIVIACT 10 MG/ML ORAL SOLN brivaracetam	50474087015 UCB PHARMA	No	No	Medicaid CHIP CSHCN
BRIVIACT 100 MG TABLET brivaracetam	50474077009 UCB PHARMA	No	No	Medicaid CHIP CSHCN