Muscle Relaxants, Oral
PDL Reference Documents
PDL Status Values
Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the
Non-Preferred Drugs in Select PDL Classes prior authorization criteria.
New drugs will be listed as N until reviewed by the P&T Committee and are subject to the
New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.
To request a Prior Authorization, please use this form.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| tizanidine HCl | TIZANIDINE HCL | TABLET | Y | N | ||
| baclofen | FLEQSUVY | ORAL SUSP | N | Pharmacy PA | N | |
| baclofen | BACLOFEN | SOLUTION | N | Pharmacy PA | N | |
| baclofen | OZOBAX | SOLUTION | N | Pharmacy PA | N | |
| baclofen | BACLOFEN | TABLET | N | Pharmacy PA | N | |
| carisoprodol | CARISOPRODOL | TABLET | N | Pharmacy PA | N | |
| carisoprodol | SOMA | TABLET | N | Pharmacy PA | N | |
| chlorzoxazone | LORZONE | TABLET | N | Pharmacy PA | N | |
| cyclobenzaprine HCl | CYCLOBENZAPRINE HCL ER | CAP ER 24H | N | Pharmacy PA | N | |
| dantrolene sodium | DANTRIUM | CAPSULE | N | Pharmacy PA | N | |
| metaxalone | METAXALONE | TABLET | N | Pharmacy PA | N | |
| orphenadrine/aspirin/caffeine | NORGESIC | TABLET | N | Pharmacy PA | N | |
| orphenadrine/aspirin/caffeine | ORPHENGESIC FORTE | TABLET | N | Pharmacy PA | N | |
| orphenadrine/aspirin/caffeine | ORPHENGESIC | TABLET | N | Pharmacy PA | N | |
| orphenadrine/aspirin/caffeine | NORGESIC FORTE | TABLET | N | Pharmacy PA | N | |
| tizanidine HCl | ZANAFLEX | CAPSULE | N | Pharmacy PA | N |