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 but eligible patients will encounter a co-pay at the pharmacy.
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 7.5 mg Require PA  
tizanidine HCl ZANAFLEX TABLET Y    
tizanidine HCl TIZANIDINE HCL TABLET Y    
carisoprodol SOMA TABLET N PA Document  
carisoprodol CARISOPRODOL TABLET N PA Document  
carisoprodol/aspirin CARISOPRODOL-ASPIRIN TABLET N PA Document  
carisoprodol/aspirin/codeine CARISOPRODOL-ASPIRIN-CODEINE TABLET N PA Document  
chlorzoxazone CHLORZOXAZONE TABLET N PA Document  
chlorzoxazone LORZONE TABLET N PA Document  
cyclobenzaprine HCl AMRIX CAP ER 24H N PA Document  
cyclobenzaprine HCl CYCLOBENZAPRINE HCL CAP ER 24H N PA Document  
dantrolene sodium DANTRIUM CAPSULE N PA Document  
dantrolene sodium DANTROLENE SODIUM CAPSULE N PA Document  
metaxalone SKELAXIN TABLET N PA Document  
metaxalone METAXALONE TABLET N PA Document  
metaxalone METAXALL TABLET N PA Document  
methocarbamol METHOCARBAMOL TABLET N PA Document  
methocarbamol ROBAXIN TABLET N PA Document  
methocarbamol ROBAXIN-750 TABLET N PA Document  
orphenadrine citrate ORPHENADRINE CITRATE TABLET ER N PA Document  
orphenadrine/aspirin/caffeine ORPHENADRINE COMPOUND FORTE TABLET N PA Document  
tizanidine HCl TIZANIDINE HCL CAPSULE N PA Document  
tizanidine HCl ZANAFLEX CAPSULE N PA Document