Tranquilizers, 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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Carveout ‐ Bill FFS |
Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|---|
| 81279012360 | BUCAPSOL | buspirone HCl | CAPSULE | 10 mg | Y | Y | ||
| 81279012460 | BUCAPSOL | buspirone HCl | CAPSULE | 15 mg | Y | Y | ||
| 81279012260 | BUCAPSOL | buspirone HCl | CAPSULE | 7.5 mg | Y | Y | ||
| 00093005401 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 00093005405 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 00378115001 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 00378115005 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 00904712161 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 16729020201 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 16729020216 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 23155002401 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 23155002405 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 24689090701 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 24689090705 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 29300024501 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 29300024505 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 42543074207 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 42806008401 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 42806008405 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 42806066301 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 42806066305 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 51079098601 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 51079098620 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 59651039101 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 59651039105 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 60505007900 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 60505007901 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 60687081201 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 60687081211 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 64380074206 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 64380074207 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 64380074208 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 68382018101 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 68382018105 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 69584009210 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 69584009250 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 72888006401 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 72888006405 | BUSPIRONE HCL | buspirone HCl | TABLET | 10 mg | Y | Y | ||
| 00093100301 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 00093100305 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 00378116505 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 00378116580 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 00378116591 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 00904689961 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 16729020301 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 16729020312 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 23155002501 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 23155002505 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 23155002506 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 23155002508 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 24689092101 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 24689092105 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 24689092106 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 29300024601 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 29300024605 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 29300024616 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 29300024618 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 29300047701 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 29300047705 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 29300047716 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 29300047718 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 42543074318 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 42806008501 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 42806008505 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 42806066401 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 42806066405 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 50268013511 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 50268013515 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 51079096001 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 51079096020 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 59651039201 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 59651039205 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 60505010300 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 60505010301 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 60687082301 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 60687082311 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 64380074303 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 64380074318 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 68382018201 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 68382018205 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 69584009306 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 69584009310 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 69584009350 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 72888006501 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 72888006505 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 72888006560 | BUSPIRONE HCL | buspirone HCl | TABLET | 15 mg | Y | Y | ||
| 00093520005 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 00093520006 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 00378117591 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 16729028912 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 23155009705 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 23155009706 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 24689093306 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 29300024705 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 29300024716 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 29300047805 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 29300047816 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 42543074403 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 42806008605 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 42806008660 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 42806066560 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 51079099401 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 51079099420 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 59651039360 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 64380074403 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 68382018305 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 68382018314 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 69117004302 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 69584009406 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 69584009450 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 72888006605 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 72888006660 | BUSPIRONE HCL | buspirone HCl | TABLET | 30 mg | Y | Y | ||
| 00093005301 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 00093005305 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 00378114001 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 00378114005 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 00904712261 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 16729020001 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 16729020016 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 23155002301 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 23155002305 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 24689078101 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 24689078105 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 29300024401 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 29300024405 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 42543074107 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 42806008201 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 42806008205 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 42806066201 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 42806066205 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 51079098501 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 51079098520 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 59651038901 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 59651038905 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 60505007800 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 60505007801 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 64380074106 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 64380074107 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 64380074108 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 68382018001 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 68382018005 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 69584009110 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 69584009150 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 72888006201 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 72888006205 | BUSPIRONE HCL | buspirone HCl | TABLET | 5 mg | Y | Y | ||
| 00378114501 | BUSPIRONE HCL | buspirone HCl | TABLET | 7.5 mg | Y | Y | ||
| 16729020101 | BUSPIRONE HCL | buspirone HCl | TABLET | 7.5 mg | Y | Y | ||
| 24689078501 | BUSPIRONE HCL | buspirone HCl | TABLET | 7.5 mg | Y | Y | ||
| 42543078706 | BUSPIRONE HCL | buspirone HCl | TABLET | 7.5 mg | Y | Y | ||
| 42806008301 | BUSPIRONE HCL | buspirone HCl | TABLET | 7.5 mg | Y | Y | ||
| 42806008305 | BUSPIRONE HCL | buspirone HCl | TABLET | 7.5 mg | Y | Y | ||
| 59651039001 | BUSPIRONE HCL | buspirone HCl | TABLET | 7.5 mg | Y | Y | ||
| 60687080111 | BUSPIRONE HCL | buspirone HCl | TABLET | 7.5 mg | Y | Y | ||
| 60687080121 | BUSPIRONE HCL | buspirone HCl | TABLET | 7.5 mg | Y | Y | ||
| 64380078706 | BUSPIRONE HCL | buspirone HCl | TABLET | 7.5 mg | Y | Y | ||
| 64380078707 | BUSPIRONE HCL | buspirone HCl | TABLET | 7.5 mg | Y | Y | ||
| 68382062301 | BUSPIRONE HCL | buspirone HCl | TABLET | 7.5 mg | Y | Y | ||
| 72888006301 | BUSPIRONE HCL | buspirone HCl | TABLET | 7.5 mg | Y | Y | ||
| 72888006305 | BUSPIRONE HCL | buspirone HCl | TABLET | 7.5 mg | Y | Y | ||
| 00409127303 | DIAZEPAM | diazepam | CARTRIDGE | 5 mg/mL | Y | Y | ||
| 00409127332 | DIAZEPAM | diazepam | CARTRIDGE | 5 mg/mL | Y | Y | ||
| 00641624401 | DIAZEPAM | diazepam | SYRINGE | 5 mg/mL | Y | Y | ||
| 00641624410 | DIAZEPAM | diazepam | SYRINGE | 5 mg/mL | Y | Y | ||
| 43598010610 | DIAZEPAM | diazepam | SYRINGE | 5 mg/mL | Y | Y | ||
| 43598010611 | DIAZEPAM | diazepam | SYRINGE | 5 mg/mL | Y | Y | ||
| 62332081102 | DIAZEPAM | diazepam | SYRINGE | 5 mg/mL | Y | Y | ||
| 62332081120 | DIAZEPAM | diazepam | SYRINGE | 5 mg/mL | Y | Y | ||
| 69339013603 | DIAZEPAM | diazepam | SYRINGE | 5 mg/mL | Y | Y | ||
| 69339013634 | DIAZEPAM | diazepam | SYRINGE | 5 mg/mL | Y | Y | ||
| 69339013693 | DIAZEPAM | diazepam | SYRINGE | 5 mg/mL | Y | Y | ||
| 69339013697 | DIAZEPAM | diazepam | SYRINGE | 5 mg/mL | Y | Y | ||
| 72572014001 | DIAZEPAM | diazepam | SYRINGE | 5 mg/mL | Y | Y | ||
| 72572014002 | DIAZEPAM | diazepam | SYRINGE | 5 mg/mL | Y | Y | ||
| 76045020400 | DIAZEPAM | diazepam | SYRINGE | 5 mg/mL | Y | Y | ||
| 76045020420 | DIAZEPAM | diazepam | SYRINGE | 5 mg/mL | Y | Y | ||
| 00004193306 | VALIUM | diazepam | SYRINGE | 5 mg/mL | Y | Y | ||
| 00409321311 | DIAZEPAM | diazepam | VIAL | 5 mg/mL | Y | Y | ||
| 00409321312 | DIAZEPAM | diazepam | VIAL | 5 mg/mL | Y | Y | ||
| 00641624301 | DIAZEPAM | diazepam | VIAL | 5 mg/mL | Y | Y | ||
| 00641624310 | DIAZEPAM | diazepam | VIAL | 5 mg/mL | Y | Y | ||
| 69339013701 | DIAZEPAM | diazepam | VIAL | 5 mg/mL | Y | Y | ||
| 69339013705 | DIAZEPAM | diazepam | VIAL | 5 mg/mL | Y | Y | ||
| 69339013791 | DIAZEPAM | diazepam | VIAL | 5 mg/mL | Y | Y | ||
| 69339013795 | DIAZEPAM | diazepam | VIAL | 5 mg/mL | Y | Y | ||
| 10019085021 | DIZAC | diazepam (in soybean oil) | AMPUL | 5 mg/mL | Y | Y | ||
| 00074226902 | DROPERIDOL | droperidol | SYRINGE | 2.5 mg/mL | Y | Y | ||
| 00143951401 | DROPERIDOL | droperidol | VIAL | 2.5 mg/mL | Y | Y | ||
| 00143951425 | DROPERIDOL | droperidol | VIAL | 2.5 mg/mL | Y | Y | ||
| 00143951501 | DROPERIDOL | droperidol | VIAL | 2.5 mg/mL | Y | Y | ||
| 00143951525 | DROPERIDOL | droperidol | VIAL | 2.5 mg/mL | Y | Y | ||
| 00517970201 | DROPERIDOL | droperidol | VIAL | 2.5 mg/mL | Y | Y | ||
| 00517970225 | DROPERIDOL | droperidol | VIAL | 2.5 mg/mL | Y | Y | ||
| 62332001931 | MEPROBAMATE | meprobamate | TABLET | 200 mg | Y | Y | ||
| 69097097407 | MEPROBAMATE | meprobamate | TABLET | 200 mg | Y | Y | ||
| 62332002031 | MEPROBAMATE | meprobamate | TABLET | 400 mg | Y | Y | ||
| 69097097507 | MEPROBAMATE | meprobamate | TABLET | 400 mg | Y | Y | ||
| 00037100103 | MILTOWN | meprobamate | TABLET | 400 mg | Y | Y | ||
| 00597002001 | SERENTIL | mesoridazine besylate | TABLET | 10 mg | Y | Y | ||
| 42806033801 | MOLINDONE HCL | molindone HCl | TABLET | 25 mg | Y | Y | ||
| 42806033601 | MOLINDONE HCL | molindone HCl | TABLET | 5 mg | Y | Y |