Muscle Relaxants, Parenteral

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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
ATRACURIUM BESYLATE ATRACURIUM BESYLATE VIAL    
BACLOFEN LIORESAL INTRATHECAL AMPUL    
BACLOFEN GABLOFEN SYRINGE    
BACLOFEN GABLOFEN VIAL    
CISATRACURIUM BESYLATE NIMBEX VIAL    
CISATRACURIUM BESYLATE CISATRACURIUM BESYLATE VIAL    
DANTROLENE SODIUM DANTRIUM VIAL    
DANTROLENE SODIUM REVONTO VIAL    
METHOCARBAMOL ROBAXIN VIAL    
METHOCARBAMOL METHOCARBAMOL VIAL    
ORPHENADRINE CITRATE ORPHENADRINE CITRATE AMPUL    
ORPHENADRINE CITRATE ORPHENADRINE CITRATE VIAL    
PANCURONIUM BROMIDE PANCURONIUM BROMIDE VIAL    
ROCURONIUM BROMIDE ROCURONIUM BROMIDE VIAL    
SUCCINYLCHOLINE CHLORIDE QUELICIN VIAL    
VECURONIUM BROMIDE VECURONIUM BROMIDE VIAL