Sedative, Misc

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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
DEXMEDETOMIDINE HCL DEXMEDETOMIDINE HCL VIAL    
DEXMEDETOMIDINE HCL PRECEDEX VIAL    
DEXMEDETOMIDINE IN 0.9 % NACL PRECEDEX INFUS. BTL    
DEXMEDETOMIDINE IN 0.9 % NACL PRECEDEX VIAL    
ETHYL ALCOHOL ALCOHOL,DEHYDRATED AMPUL    
ETHYL ALCOHOL ALCOHOL,DEHYDRATED VIAL    
LORAZEPAM LORAZEPAM SYRINGE    
LORAZEPAM ATIVAN VIAL    
LORAZEPAM LORAZEPAM VIAL    
SODIUM OXYBATE XYREM SOLUTION