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 TIZANIDINE HCL TABLET Y    
TIZANIDINE HCL ZANAFLEX 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 LORZONE TABLET N PA Document  
CHLORZOXAZONE CHLORZOXAZONE TABLET N PA Document  
CYCLOBENZAPRINE HCL AMRIX CAP ER 24H N PA Document  
CYCLOBENZAPRINE HCL FEXMID TABLET N PA Document  
DANTROLENE SODIUM DANTROLENE SODIUM CAPSULE N PA Document  
DANTROLENE SODIUM DANTRIUM CAPSULE N PA Document  
METAXALONE METAXALL TABLET N PA Document  
METAXALONE METAXALONE TABLET N PA Document  
METAXALONE SKELAXIN TABLET N PA Document  
METHOCARBAMOL ROBAXIN-750 TABLET N PA Document  
METHOCARBAMOL ROBAXIN TABLET N PA Document  
METHOCARBAMOL METHOCARBAMOL TABLET N PA Document  
ORPHENADRINE CITRATE ORPHENADRINE CITRATE TABLET ER N PA Document  
TIZANIDINE HCL ZANAFLEX CAPSULE N PA Document  
TIZANIDINE HCL TIZANIDINE HCL CAPSULE N PA Document