Muscle Relaxants, Oral

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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.

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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