(continued)
DRUG CLASS
EXCLUDED MEDICATIONS
PREFERRED ALTERNATIVES
Anticonvulsants
FINTEPLA
DIACOMIT, EPIDIOLEX
GABARONE, RELGAABI 200MG
gabapentin capsules (100mg, 300mg, 400mg), solution, tablets levetiracetam oral solution, levetiracetam tablets diazepam rectal gel, NAYZILAM, VALTOCO
LEVETIRACETAM ODT
LIBERVANT MOTPOLY XR
lacosamide
PRIMIDONE 125MG TABLETS SUBVENITE SUSPENSION
primidone 50mg or 250mg tablets
lamotrigine chewable dispersible tablets, lamotrigine odt
TOPIRAMATE 50MG SPRINKLE CAPSULES
topiramate solution, topiramate 25mg sprinkle capsules vigabatrin powder packets
VIGAFYDE ZONISADE
zonisamide
Antimigraine Agents
BREKIYA, TRUDHESA
dihydroergotamine nasal, almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan or zolmitriptan tablets
zolmitriptan 5mg nasal, ONZETRA XSAIL, ZOLMITRIPTAN 2.5MG NASAL, ZOMIG NASAL sumatriptan/naproxen sodium, TREXIMET
sumatriptan nasal
etodolac, flurbiprofen, ibuprofen, ketoprofen, meloxicam capsules or tablets, nabumetone, naproxen or oxaprozin plus almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan or zolmitriptan tablets
VYEPTI
AIMOVIG, AJOVY, EMGALITY
ZAVZPRET
eletriptan, naratriptan, rizatriptan, sumatriptan, NURTEC ODT, UBRELVY Coverage may be approved for the treatment of Parkinson’s Disease under certain conditions.
Antiparkinsonism Agents
APOKYN
CARBIDOPA/LEVODOPA ER CAPSULES, ONAPGO, VYALEV
carbidopa/levodopa er tablets
DHIVY
carbidopa/levodopa
GOCOVRI ER
amantadine
NOURIANZ
cabergoline, entacapone, pramipexole, rasagiline, ropinirole
XADAGO, ZELAPAR
rasagiline, selegiline
Antipsychotics (Oral)
BYSANTI, COBENFY, FANAPT
aripiprazole, asenapine, lurasidone, olanzapine, paliperidone er, quetiapine (except 150mg), risperidone, ziprasidone
OPIPZA
aripiprazole odt or oral solution quetiapine 50mg or 100mg tablets baclofen solution, suspension or tablets metaxalone 400mg or 800mg tablets tizanidine 2mg, 4mg or 6mg capsules, tizanidine tablets
QUETIAPINE 150MG TABLETS
Antispasmodic Agents
LYVISPAH, OZOBAX
METAXALONE 640MG TABLETS
ONTRALFY, TIZANIDINE HCL 8MG CAPSULES, ZANAFLEX 8MG CAPSULES
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