Muscle Relaxants, Oral

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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
baclofen BACLOFEN TABLET Y    
cyclobenzaprine HCl CYCLOBENZAPRINE HCL TABLET Y    
methocarbamol METHOCARBAMOL TABLET Y    
tizanidine HCl ZANAFLEX TABLET Y    
tizanidine HCl TIZANIDINE HCL TABLET Y    
baclofen LYVISPAH GRAN PACK N PA Document  
baclofen BACLOFEN ORAL SUSP N PA Document  
baclofen FLEQSUVY ORAL SUSP N PA Document  
baclofen BACLOFEN SOLUTION N PA Document  
carisoprodol CARISOPRODOL TABLET N PA Document  
carisoprodol SOMA TABLET N PA Document  
chlorzoxazone LORZONE TABLET N PA Document  
chlorzoxazone CHLORZOXAZONE TABLET N PA Document  
cyclobenzaprine HCl CYCLOBENZAPRINE HCL ER CAP ER 24H N PA Document  
cyclobenzaprine HCl AMRIX CAP ER 24H N PA Document  
cyclobenzaprine HCl FEXMID TABLET N PA Document  
cyclobenzaprine HCl CYCLOBENZAPRINE HCL TABLET N PA Document  
dantrolene sodium DANTROLENE SODIUM CAPSULE N PA Document  
dantrolene sodium DANTRIUM CAPSULE N PA Document  
metaxalone METAXALONE TABLET N PA Document  
orphenadrine citrate ORPHENADRINE CITRATE ER TABLET ER N PA Document  
orphenadrine/aspirin/caffeine ORPHENGESIC TABLET N PA Document  
orphenadrine/aspirin/caffeine ORPHENGESIC FORTE TABLET N PA Document  
orphenadrine/aspirin/caffeine ORPHENADRINE-ASPIRIN-CAFFEINE TABLET N PA Document  
orphenadrine/aspirin/caffeine NORGESIC FORTE TABLET N PA Document  
orphenadrine/aspirin/caffeine NORGESIC TABLET N PA Document  
tizanidine HCl ZANAFLEX CAPSULE N PA Document  
tizanidine HCl TIZANIDINE HCL CAPSULE N PA Document