Anesthetics Gen Injection

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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
ETOMIDATE AMIDATE SYRINGE    
ETOMIDATE ETOMIDATE VIAL    
ETOMIDATE AMIDATE VIAL    
KETAMINE HCL KETAMINE HCL VIAL    
KETAMINE HCL KETALAR VIAL    
METHOHEXITAL SODIUM BREVITAL SODIUM VIAL    
MIDAZOLAM HCL MIDAZOLAM HCL VIAL    
MIDAZOLAM HCL/PF MIDAZOLAM HCL CARTRIDGE    
MIDAZOLAM HCL/PF MIDAZOLAM HCL SYRINGE    
MIDAZOLAM HCL/PF MIDAZOLAM HCL VIAL    
PROPOFOL PROPOFOL VIAL    
PROPOFOL DIPRIVAN VIAL    
PROPOFOL/PF PROPOVEN AMPUL