Muscle Relaxants, Oral
PDL Reference Documents
- Skeletal Muscal Relaxants - Sep 26, 2019
- Skeletal Muscle Relaxants Class Update - Mar 23, 2017
- Skeletal Muscle Relaxants DERP Scan - Nov 20, 2014
- Skeletal Muscle Relaxants Scan Summary - Nov 20, 2014
- NSAIDs Scan Summary - Nov 20, 2014
- Skeletal Muscle Relaxant Scan Summary - Nov 21, 2013
- Class Scan: Skeletal Muscle Relaxants - Mar 29, 2012
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 |