Benzodiazepines

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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
CLONAZEPAM KLONOPIN TABLET Y Quantity Limit  
CLONAZEPAM CLONAZEPAM TABLET Y Quantity Limit  
CLONAZEPAM CLONAZEPAM TAB RAPDIS N Quantity Limit  
DIAZEPAM DIAZEPAM SOLUTION N Quantity Limit  
ALPRAZOLAM ALPRAZOLAM INTENSOL ORAL CONC Quantity Limit  
ALPRAZOLAM ALPRAZOLAM XR TAB ER 24H Quantity Limit  
ALPRAZOLAM XANAX XR TAB ER 24H Quantity Limit  
ALPRAZOLAM ALPRAZOLAM ER TAB ER 24H Quantity Limit  
ALPRAZOLAM ALPRAZOLAM ODT TAB RAPDIS Quantity Limit  
ALPRAZOLAM ALPRAZOLAM TABLET Quantity Limit  
ALPRAZOLAM XANAX TABLET Quantity Limit  
AMITRIPTYLINE/CHLORDIAZEPOXIDE CHLORDIAZEPOXIDE-AMITRIPTYLINE TABLET Quantity Limit  
CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE HCL CAPSULE Quantity Limit  
CHLORDIAZEPOXIDE/CLIDINIUM BR LIBRAX CAPSULE Quantity Limit  
CHLORDIAZEPOXIDE/CLIDINIUM BR CHLORDIAZEPOXIDE-CLIDINIUM CAPSULE Quantity Limit  
CLORAZEPATE DIPOTASSIUM CLORAZEPATE DIPOTASSIUM TABLET Quantity Limit  
CLORAZEPATE DIPOTASSIUM TRANXENE T-TAB TABLET Quantity Limit  
DIAZEPAM DIAZEPAM ORAL CONC Quantity Limit  
DIAZEPAM DIAZEPAM SOLUTION Quantity Limit  
DIAZEPAM DIAZEPAM TABLET Quantity Limit  
LORAZEPAM LORAZEPAM ORAL CONC Quantity Limit  
LORAZEPAM LORAZEPAM INTENSOL ORAL CONC Quantity Limit  
LORAZEPAM LORAZEPAM TABLET Quantity Limit  
LORAZEPAM ATIVAN TABLET Quantity Limit  
OXAZEPAM OXAZEPAM CAPSULE Quantity Limit