Muscle Relaxants, Parenteral
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 |
|---|---|---|---|---|---|---|
| atracurium besylate | ATRACURIUM BESYLATE | VIAL | N | |||
| baclofen | GABLOFEN | SYRINGE | N | |||
| baclofen | BACLOFEN | SYRINGE | N | |||
| cisatracurium besylate | CISATRACURIUM BESYLATE | VIAL | N | |||
| dantrolene sodium | REVONTO | VIAL | N | |||
| dantrolene sodium | DANTRIUM | VIAL | N | |||
| rocuronium bromide | ROCURONIUM BROMIDE | VIAL | N | |||
| succinylcholine chloride | SUX-CERT 500 | IRRIG SOLN | N | |||
| succinylcholine chloride | SUX-CERT 1000 | IRRIG SOLN | N | |||
| succinylcholine chloride | QUELICIN | VIAL | N | |||
| succinylcholine/sod Cl,iso/PF | SUCCINYLCHOLINE CHLORIDE | SYRINGE | N | |||
| tubocurarine chloride | TUBOCURARINE CHLORIDE | VIAL | N | |||
| vecuronium bromide | VECURONIUM BROMIDE | VIAL | N |