Anesthetics Gen Injection
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 |
|---|---|---|---|---|---|
| etomidate | AMIDATE | VIAL | |||
| etomidate | ETOMIDATE | VIAL | |||
| ketamine HCl | KETAMINE HCL | VIAL | |||
| ketamine HCl | KETALAR | VIAL | |||
| methohexital sodium | BREVITAL SODIUM | VIAL | |||
| midazolam HCl | VERSED | SYRINGE | |||
| midazolam HCl | MIDAZOLAM HCL | SYRINGE | |||
| midazolam HCl | MIDAZOLAM HCL | VIAL | |||
| midazolam HCl in 0.9 % NaCl/PF | MIDAZOLAM HCL-0.9% NACL | PLAST. BAG | |||
| midazolam HCl/PF | MIDAZOLAM HCL | SYRINGE | |||
| midazolam HCl/PF | MIDAZOLAM HCL | VIAL | |||
| midazolam in NaCl,iso-osmot/PF | MIDAZOLAM HCL-0.8% NACL | VIAL | |||
| propofol | DIPRIVAN | AMPUL | |||
| propofol | PROPOFOL | VIAL | |||
| propofol | DIPRIVAN | VIAL | |||
| propofol in lipid MCT/LCT/PF | PROPOFOL-LIPURO | VIAL | |||
| propofol in lipid MCT/LCT/PF | PROPOVEN (EUA) | VIAL | |||
| remimazolam besylate | BYFAVO | VIAL |