Tranquilizers, Misc
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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| buspirone HCl | BUCAPSOL | CAPSULE | Y | |||
| diazepam | DIAZEPAM | CARTRIDGE | Y | |||
| diazepam | DIAZEPAM | VIAL | Y | |||
| diazepam (in soybean oil) | DIZAC | AMPUL | Y | |||
| meprobamate | MEPROBAMATE | TABLET | Y | |||
| mesoridazine besylate | SERENTIL | TABLET | Y |