Drug Name Tier Notes zonisamide oral capsule 2 QL *CARBAMATES*** felbamate oral suspension 2 QL felbamate oral tablet 2 QL *GABA MODULATORS*** tiagabine hcl oral tablet 2 QL vigabatrin oral packet 4 LD; QL; SP vigabatrin oral tablet 4 LD; QL; SP vigadrone oral packet 4 LD; QL VIGADRONE ORAL TABLET 4 LD; QL; SP *HYDANTOINS*** DILANTIN ORAL CAPSULE 30 MG 2 fosphenytoin sodium injection solution 2 PHENYTEK ORAL CAPSULE 1 or 1b* phenytoin infatabs oral tablet chewable 1 or 1b* phenytoin oral suspension 125 mg/5ml 1 or 1b* phenytoin oral tablet chewable 1 or 1b* phenytoin sodium extended oral capsule 1 or 1b* phenytoin sodium injection solution 1 or 1b* *SUCCINIMIDES*** ethosuximide oral capsule 1 or 1b* QL ethosuximide oral solution 1 or 1b* QL methsuximide oral capsule 2 QL *VALPROIC ACID*** divalproex sodium er oral tablet extended release 24 hour 1 or 1b* QL divalproex sodium oral capsule delayed release sprinkle 1 or 1b* QL divalproex sodium oral tablet delayed release 1 or 1b* QL valproate sodium intravenous solution 100 mg/ml, 500 mg/5ml 1 or 1b* valproic acid oral capsule 1 or 1b* QL valproic acid oral solution 1 or 1b* Drug Name Tier Notes *ANTIDEPRESSANTS* *ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)*** mirtazapine oral tablet 1 or 1b* mirtazapine oral tablet dispersible 1 or 1b* *ANTIDEPRESSANTS - MISC.*** bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg 1 or 1b* DO bupropion hcl er (sr) oral tablet extended release 12 hour 150 mg, 200 mg 1 or 1b* QL bupropion hcl er (xl) oral tablet extended release 24 hour 1 or 1b* QL bupropion hcl oral tablet 100 mg 1 or 1b* QL bupropion hcl oral tablet 75 mg 1 or 1b* DO *MONOAMINE OXIDASE INHIBITORS (MAOIS)*** phenelzine sulfate oral tablet 1 or 1b* QL tranylcypromine sulfate oral tablet 1 or 1b* QL *SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)*** citalopram hydrobromide oral solution 1 or 1b* citalopram hydrobromide oral tablet 1 or 1b* escitalopram oxalate oral solution 1 or 1b* escitalopram oxalate oral tablet 1 or 1b* fluoxetine hcl oral capsule 1 or 1b* fluoxetine hcl oral capsule delayed release 1 or 1b* fluoxetine hcl oral solution 1 or 1b* fluoxetine hcl oral tablet 10 mg, 20 mg 1 or 1b* fluvoxamine maleate er oral capsule extended release 24 hour 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 20