Drug Name Tier Notes carbamazepine er oral tablet extended release 12 hour 1 or 1b* QL carbamazepine oral suspension 1 or 1b* QL carbamazepine oral tablet 1 or 1b* QL carbamazepine oral tablet chewable 1 or 1b* QL EPIDIOLEX ORAL SOLUTION 4 PA; LD; SP epitol oral tablet 1 or 1b* QL eslicarbazepine acetate oral tablet 200 mg, 400 mg 2 DO eslicarbazepine acetate oral tablet 600 mg, 800 mg 2 QL gabapentin oral capsule 1 or 1b* DO gabapentin oral solution 2 QL gabapentin oral tablet 600 mg, 800 mg 1 or 1b* QL lacosamide intravenous solution 2 lacosamide oral solution 2 QL lacosamide oral tablet 2 QL lamotrigine er oral tablet extended release 24 hour 100 mg, 25 mg, 50 mg 1 or 1b* DO lamotrigine er oral tablet extended release 24 hour 200 mg, 250 mg, 300 mg 1 or 1b* QL lamotrigine oral kit 21 x 25 mg & 7 x 50 mg, 25 & 50 & 100 mg, 42 x 50 mg & 14x100 mg 1 or 1b* QL lamotrigine oral tablet 1 or 1b* DO lamotrigine oral tablet chewable 1 or 1b* QL lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg 1 or 1b* QL lamotrigine oral tablet dispersible 50 mg 1 or 1b* DO lamotrigine starter kit-blue oral kit 1 or 1b* QL lamotrigine starter kit-green oral kit 1 or 1b* QL lamotrigine starter kit-orange oral kit 1 or 1b* QL levetiracetam er oral tablet extended release 24 hour 2 QL Drug Name Tier Notes levetiracetam intravenous solution 2 levetiracetam oral solution 2 QL levetiracetam oral tablet 1000 mg 2 QL levetiracetam oral tablet 250 mg, 500 mg, 750 mg 2 DO oxcarbazepine er oral tablet extended release 24 hour 150 mg, 300 mg 2 DO oxcarbazepine er oral tablet extended release 24 hour 600 mg 2 QL oxcarbazepine oral suspension 1 or 1b* QL oxcarbazepine oral tablet 1 or 1b* QL pregabalin oral capsule 2 QL pregabalin oral solution 2 QL primidone oral tablet 1 or 1b* QL roweepra oral tablet 500 mg 2 DO rufinamide oral suspension 2 QL rufinamide oral tablet 200 mg 2 DO rufinamide oral tablet 400 mg 2 QL subvenite oral tablet 1 or 1b* DO subvenite starter kit-blue oral kit 1 or 1b* QL subvenite starter kit-green oral kit 1 or 1b* QL subvenite starter kit-orange oral kit 1 or 1b* QL topiramate er oral capsule er 24 hour sprinkle 100 mg, 150 mg, 200 mg, 50 mg 1 or 1b* QL topiramate er oral capsule er 24 hour sprinkle 25 mg 1 or 1b* DO topiramate er oral capsule extended release 24 hour 100 mg, 200 mg, 50 mg 2 QL topiramate er oral capsule extended release 24 hour 25 mg 2 DO topiramate oral capsule sprinkle 15 mg, 25 mg 1 or 1b* QL topiramate oral tablet 100 mg, 25 mg, 50 mg 1 or 1b* DO topiramate oral tablet 200 mg 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 19