Benzodiazepines
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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.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| clonazepam | CLONAZEPAM | TABLET | Y | Quantity Limit | ||
| clonazepam | KLONOPIN | TABLET | Y | Quantity Limit | ||
| clonazepam | CLONAZEPAM | TAB RAPDIS | N | Quantity Limit | ||
| alprazolam | ALPRAZOLAM INTENSOL | ORAL CONC | Quantity Limit | BILL FFS | ||
| alprazolam | XANAX XR | TAB ER 24H | Quantity Limit | BILL FFS | ||
| alprazolam | ALPRAZOLAM XR | TAB ER 24H | Quantity Limit | BILL FFS | ||
| alprazolam | ALPRAZOLAM ER | TAB ER 24H | Quantity Limit | BILL FFS | ||
| alprazolam | ALPRAZOLAM ODT | TAB RAPDIS | Quantity Limit | BILL FFS | ||
| alprazolam | XANAX | TABLET | Quantity Limit | BILL FFS | ||
| alprazolam | ALPRAZOLAM | TABLET | Quantity Limit | BILL FFS | ||
| amitriptyline/chlordiazepoxide | CHLORDIAZEPOXIDE-AMITRIPTYLINE | TABLET | Quantity Limit | BILL FFS | ||
| chlordiazepoxide HCl | CHLORDIAZEPOXIDE HCL | CAPSULE | Quantity Limit | BILL FFS | ||
| chlordiazepoxide/clidinium Br | CHLORDIAZEPOXIDE-CLIDINIUM | CAPSULE | Quantity Limit | |||
| clorazepate dipotassium | CLORAZEPATE DIPOTASSIUM | TABLET | Quantity Limit | BILL FFS | ||
| diazepam | DIAZEPAM | ORAL CONC | Quantity Limit | BILL FFS | ||
| diazepam | DIAZEPAM | SOLUTION | Quantity Limit | BILL FFS | ||
| diazepam | DIAZEPAM | TABLET | Quantity Limit | BILL FFS | ||
| lorazepam | LOREEV XR | CAP ER 24H | Quantity Limit | BILL FFS | ||
| lorazepam | LORAZEPAM INTENSOL | ORAL CONC | Quantity Limit | BILL FFS | ||
| lorazepam | LORAZEPAM | ORAL CONC | Quantity Limit | BILL FFS | ||
| lorazepam | LORAZEPAM | TABLET | Quantity Limit | BILL FFS | ||
| oxazepam | OXAZEPAM | CAPSULE | Quantity Limit | BILL FFS |