Anticonvulsants

PHARM-13 Statement of Medical Necessity for Quantity Limits Override

Anticonvulsants.xls

Anticonvulsants

Drugs

Quantity Limits

Banzel (Rufinamide) 200mg Tablets

90 Tablets per 30 days

Banzel (Rufinamide) 400mg Tablets

240 Tablets per 30 days

Carbatrol (Carbamazepine) 100mg, 200mg, 300mg Capsules

150 Capsules per 30 days

Celontin (Methosuximide) 300mg Capsules

150 Capsules per 30 days

Dilantin (Phenytoin) 50mg Chewable Tablets

180 Tablets per 30 days

Dilantin (Phenytoin 100mg EX Capsules

180 Capsules per 30 days

Dilantin (Phenytoin) 125mg/5ml Suspension

360 mls per 30 days

Phenytoin 100mg/4ml Suspension

360 mls per 30 days

Depacon (Valproate Sodium) IV 500mg/5ml Vial

1350 mls per 30 days

Depakene (Valproic Acid) 250mg Capsules

120 Capsules per 30 days

Depakene (Valproate Sodium) 250mg/5ml Syrup

900 mls per 30 days

Depakote (Divilproex Sodium) 125mg, 250mg Tablets DR

90 Tablets per 30 days

Depakote (Divilproex Sodium) 500mg Tablets DR

270 Tablets per 30 days

Depakote ER (Divilproex Sodium) 250mg Tablets SR 24H

90 Tablets per 30 days

Depakote ER (Divilproex Sodium) 500mg Tablets SR 24H

270 Tablets per 30 days

Depakote Sprinkle (Divilproex Sodium) 125mg Capsules

360 Capsules per 30 days

Equetro (Carbamazepine) 100mg Capsules

90 Capsules per 30 days

Equetro (Carbamazepine) 200mg Capsules

120 Capsules per 30 days

Equetro (Carbamazepine) 300mg Capsules

150 Capsules per 30 days

Felbatol (Felbamate) 400mg Tablets

240 Tablets per 30 days

Felbatol (Felbamate) 600mg Tablets

150 Tablets per 30 days

Keppra (Levetiracetam) 250mg, 500mg Tablets

60 Tablets per 30 days

Keppra (Levetiracetam) 750mg, 1000mg Tablets

90 Tablets per 30 days

Keppra (Levetiracetam) 100mg/ml, 500mg/ml Solution

900 mls per 30 days

Keppra XR (Levetiracetam) 500mg Tablets SR 24H

60 Tablets per 30 days

Keppra XR (Levetiracetam) 750mg Tablets SR 24H

120 Tablets per 30 days

Lamictal (Lamotrigine) 25mg Tablets

120 Tablets per 30 days

Lamictal (Lamotrigine) 100mg Tablets

60 Tablets per 30 days

Lamictal (Lamotrigine) 150mg, 200mg Tablets

90 Tablets per 30 days

Lamictal (Lamotrigine) 5mg Disper Tablets

240 Tablets per 30 days

Lamictal (Lamotrigine) 25mg Disper Tablets

120 Tablets per 30 days

Lamictal ODT (Lamotrigine) 25mg, 50mg, 100mg, 200mg Rapdis Tablets

90 Tablets per 30 days

Lamictal XR (Lamotrigine) 25mg, 50mg, 100mg, 200mg Tablets ER 24

30 Tablets per 30 days

Lamictal XR (Lamotrigine) 300mg Tablets ER 24

90 Tablets per 30 days

Lyrica (Pregabalin) 25mg, 50mg, 75mg, 100mg, 150mg Capsules

90 Capsules per 30 days

Lyrica (Pregabalin) 200mg, 225mg, 300mg Capsules

60 Capsules per 30 days

Mysoline (Primidone) 50mg Tablets

120 Tablets per 30 days

Mysoline (Primidone) 250mg Tablets

240 Tablets per 30 days

Neurontin (Gabapentin) 100mg, 300mg, 400mg Capsules

90 Capsules per 30 days

Neurontin (Gabapentin) 250mg/5ml Solution

2250 mls per 30 days

Neurontin (Gabapentin) 600mg Tablets

180 Tablets per 30 days

Neurontin (Gabapentin) 800mg Tablets

120 Tablets per 30 days

Phenytek (Phenytoin) 100mg Capsules

120 Capsules per 30 days

Phenytek (Phenytoin) 200mg Capsules

90 Capsules per 30 days

Phenytek (Phenytoin) 300mg Capsules

60 Capsules per 30 days

Stavzor (Valproioc Acid) 125mg, 250mg Capsules DR

120 Capsules per 30 days

Stavzor (Valproioc Acid) 500mg Capsules DR

270 Capsules per 30 days

Tegretol (Carbamazepine) 100mg Chewable Tablets

300 Tablets per 30 days

Tegretol (Carbamazepine) 200mg Tablets

240 Tablets per 30 days

Tegretol (Carbamazepine) 100mg/5ml Suspension

1500 mls per 30 days

Tegretol XR (Carbamazepine) 100mg, 200mg Tablets ER 12H

90 Tablets per 30 days

Tegretol  XR (Carbamazepine) 400mg Tablets ER 12H

120 Tablets per 30 days

Topamax (Topiramate) 25mg, 50mg, 100mg, 200mg Tablets

60 Tablets per 30 days

Topamax  Sprinkle (Topiramate) 15mg, 25mg Capsules

120 Capsules per 30 days

Trileptal (Oxcarbamazepine) 150mg, 350mg Tablets

90 Tablets per 30 days

Trileptal (Oxcarbamazepine) 650mg Tablets

120 Tablets per 30 days

Trileptal (Oxcarbamazepine) 300mg/5ml Suspension

1200 mls per 30 days

Vimpat (Lacosamide) 50mg, 100mg, 150mg, 200mg Tablets

60 Tablets per 30 days

Zarontin (Ethosuximide) 250mg Capsules

180 Capsules per 30 days

Zonegran (Zonisamide) 25mg, 50mg Capsules

90 Capsules per 30 days

Zonegran (Zonisamide) 100mg Capsules

180 Capsules per 30 days