Sedative, Misc
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 |
|---|---|---|---|---|---|---|
| dexmedetomidine HCl | IGALMI | FILM | N | |||
| dexmedetomidine HCl | PRECEDEX | VIAL | N | |||
| dexmedetomidine HCl | DEXMEDETOMIDINE HCL | VIAL | N | |||
| dexmedetomidine in 0.9 % NaCl | PRECEDEX | INFUS. BTL | N | |||
| dexmedetomidine in 0.9 % NaCl | DEXMEDETOMIDINE-0.9% NACL | INFUS. BTL | N | |||
| dexmedetomidine in 0.9 % NaCl | PRECEDEX | PLAST. BAG | N | |||
| dexmedetomidine in 0.9 % NaCl | DEXMEDETOMIDINE-0.9% NACL | PLAST. BAG | N | |||
| dexmedetomidine in 0.9 % NaCl | PRECEDEX | VIAL | N | |||
| dexmedetomidine in 0.9 % NaCl | DEXMEDETOMIDINE-0.9% NACL | VIAL | N | |||
| dexmedetomidine in dextrose 5% | DEXMEDETOMIDINE-D5W | PLAST. BAG | N | |||
| lorazepam | LORAZEPAM | CARTRIDGE | N | |||
| lorazepam | LORAZEPAM | SYRINGE | N | |||
| lorazepam | ATIVAN | SYRINGE | N | |||
| lorazepam | LORAZEPAM | VIAL | N | |||
| lorazepam | ATIVAN | VIAL | N |