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 |
|---|---|---|---|---|---|---|---|---|
| 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 |