Drug searchPlanUsingYour
CENTRAL NERVOUS SYSTEM AGENTS
ANTICONVULSANT AGENTS
** Ingredient Cost Per Therapy

 Click on notes for additional information
Brand/Generic Name Dosage/Strength Status Notes Ingredient Cost
CarBAMazepine generic.gif (400 bytes)
CarBAMazepine 		  approved.gif (510 bytes)   $10-$20
Carbatrol generic.gif (400 bytes)
CarBAMazepine 		  nonform.gif (625 bytes)   Unknown
Celontin
Methsuximide 		  nonform.gif (625 bytes)   Unknown
Depakene
Valproic Acid 		  goldstar.gif (400 bytes)   $400-$450
Depakote generic.gif (400 bytes)
Divalproex Sodium 		  approved.gif (510 bytes)   $150-$175
Depakote ER generic.gif (400 bytes)
Divalproex Sodium 		  approved.gif (510 bytes)   $125-$150
Depakote Sprinkles generic.gif (400 bytes)
Divalproex Sodium 		  approved.gif (510 bytes)   $150-$175
Diastat
Diazepam 		  approved.gif (510 bytes)

NOTES.gif (377 bytes)

 $250-$300
Dilantin
Phenytoin 		  goldstar.gif (400 bytes)   $30-$40
Equetro
CarBAMazepine (Antipsychotic) 		Capsule SR 12 HR   nonform.gif (625 bytes)   Unknown
Ethosuximide
Ethosuximide 		  approved.gif (510 bytes)   $60-$70
Felbatol
Felbamate 		  approved.gif (510 bytes)   $350-$400
Gabitril
TiaGABine HCl 		  approved.gif (510 bytes)   $200-$250
Keppra generic.gif (400 bytes)
Levetiracetam 		  approved.gif (510 bytes)   $250-$300
KlonoPIN generic.gif (400 bytes)
ClonazePAM 		  approved.gif (510 bytes)   $10-$20
KlonoPIN Wafer generic.gif (400 bytes)
ClonazePAM 		  nonform.gif (625 bytes)   Unknown
LaMICtal generic.gif (400 bytes)
LamoTRIgine 		  approved.gif (510 bytes)   $250-$300
LaMICtal ODT generic.gif (400 bytes)
LamoTRIgine 		  nonform.gif (625 bytes)   Unknown
Lyrica
Pregabalin 		  priorauth.gif (816 bytes)

NOTES.gif (377 bytes)

 $125-$150
Mebaral
Mephobarbital 		  approved.gif (510 bytes)   $90-$100
Mysoline 250 mg generic.gif (400 bytes)
Primidone 		Tab - 250 mg   nonform.gif (625 bytes)   Unknown
Mysoline 50 mg generic.gif (400 bytes)
Primidone 		Tab - 50 mg   approved.gif (510 bytes)   $40-$50
Neurontin generic.gif (400 bytes)
Gabapentin 		  approved.gif (510 bytes)   $50-$60
Peganone
Ethotoin 		  nonform.gif (625 bytes)   Unknown
PHENobarbital generic.gif (400 bytes)
PHENobarbital 		  approved.gif (510 bytes)   < $10
Phenytek
Phenytoin Sodium Extended 		  approved.gif (510 bytes)   $30-$40
Primidone generic.gif (400 bytes)
Primidone 		  approved.gif (510 bytes)   $40-$50
TEGretol generic.gif (400 bytes)
CarBAMazepine 		  approved.gif (510 bytes)   $90-$100
TEGretol XR generic.gif (400 bytes)
CarBAMazepine 		  approved.gif (510 bytes)   $80-$90
Topamax generic.gif (400 bytes)
Topiramate 		  approved.gif (510 bytes)   $200-$250
Trileptal generic.gif (400 bytes)
OXcarbazepine 		  nonform.gif (625 bytes)   Unknown
Valproic Acid
Valproic Acid 		  approved.gif (510 bytes)   $30-$40
Zarontin
Ethosuximide 		  goldstar.gif (400 bytes)   $100-$125
Zarontin
Ethosuximide 		Syrup   goldstar.gif (400 bytes)   $100-$125
Zonegran generic.gif (400 bytes)
Zonisamide 		  nonform.gif (625 bytes)   Unknown

Key for Product(s) Listed Above
(click on symbol for full definition)
Click here for an explanation of these icons.
Formulary

(Brand non-formulary if Generic available)		 Click here for an explanation of these icons. 
Prior Authorization Required

(Once approved Brand and Generic, if available, are formulary)		 Click here for an explanation of these icons.
Non-Formulary

(Brand and Generic, if available, are non-formulary)
Click here for an explanation of these icons. Not Reimbursed Click here for an explanation of these icons. Generic Available Additional notes exist for this drug.Additional restrictions exist for this drug.Notes or Restrictions
  Click here for an explanation of these icons. Brand and Generic are Formulary  

Disclaimer: This is not a comprehensive list of all products covered on the formulary. Formulary status, ingredient cost, and/or copay may vary subject to availability of newly approved dosage forms and/or strengths.
If you have additional questions regarding your prescription drug benefit, please contact Member Services.

©2002 MediMedia USA, Inc. All Rights Reserved