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
estazolam ESTAZOLAM TABLET N    
flurazepam HCl FLURAZEPAM HCL CAPSULE N    
midazolam HCl MIDAZOLAM HCL SYRUP N    
temazepam TEMAZEPAM CAPSULE N    
temazepam RESTORIL CAPSULE N    
triazolam HALCION TABLET N    
triazolam TRIAZOLAM TABLET N    
dexmedetomidine HCl PRECEDEX VIAL    
dexmedetomidine HCl DEXMEDETOMIDINE HCL 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 LORAZEPAM VIAL    
lorazepam ATIVAN VIAL    
sodium oxybate XYREM SOLUTION