Tranquilizers, Misc

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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 New Drug Evaluation
buspirone HCl BUSPIRONE HCL TABLET    
diazepam DIAZEPAM CARTRIDGE    
diazepam DIAZEPAM SYRINGE    
diazepam VALIUM SYRINGE    
diazepam DIAZEPAM VIAL    
diazepam (in soybean oil) DIZAC AMPUL    
droperidol DROPERIDOL SYRINGE    
droperidol DROPERIDOL VIAL    
meprobamate MEPROBAMATE TABLET    
meprobamate MILTOWN TABLET    
mesoridazine besylate SERENTIL TABLET    
molindone HCl MOLINDONE HCL TABLET