Sedative, Barbiturate
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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 24201001020 | PENTOBARBITAL SODIUM | pentobarbital sodium | VIAL | 50 mg/mL | Y | ||
| 24201001050 | PENTOBARBITAL SODIUM | pentobarbital sodium | VIAL | 50 mg/mL | Y | ||
| 25021067620 | PENTOBARBITAL SODIUM | pentobarbital sodium | VIAL | 50 mg/mL | Y | ||
| 25021067650 | PENTOBARBITAL SODIUM | pentobarbital sodium | VIAL | 50 mg/mL | Y | ||
| 00074234301 | LUMINAL SODIUM | phenobarbital sodium | SYRINGE | 60 mg/mL | Y | ||
| 62756030101 | SEZABY | phenobarbital sodium | VIAL | 100 mg | Y | ||
| 00641047721 | PHENOBARBITAL SODIUM | phenobarbital sodium | VIAL | 130 mg/mL | Y | ||
| 00641047725 | PHENOBARBITAL SODIUM | phenobarbital sodium | VIAL | 130 mg/mL | Y | ||
| 14789012805 | PHENOBARBITAL SODIUM | phenobarbital sodium | VIAL | 130 mg/mL | Y | ||
| 14789012807 | PHENOBARBITAL SODIUM | phenobarbital sodium | VIAL | 130 mg/mL | Y | ||
| 42494041601 | PHENOBARBITAL SODIUM | phenobarbital sodium | VIAL | 130 mg/mL | Y | ||
| 42494041603 | PHENOBARBITAL SODIUM | phenobarbital sodium | VIAL | 130 mg/mL | Y | ||
| 42494041625 | PHENOBARBITAL SODIUM | phenobarbital sodium | VIAL | 130 mg/mL | Y | ||
| 42494044201 | PHENOBARBITAL SODIUM | phenobarbital sodium | VIAL | 130 mg/mL | Y | ||
| 42494044225 | PHENOBARBITAL SODIUM | phenobarbital sodium | VIAL | 130 mg/mL | Y | ||
| 00641047621 | PHENOBARBITAL SODIUM | phenobarbital sodium | VIAL | 65 mg/mL | Y | ||
| 00641047625 | PHENOBARBITAL SODIUM | phenobarbital sodium | VIAL | 65 mg/mL | Y | ||
| 14789012705 | PHENOBARBITAL SODIUM | phenobarbital sodium | VIAL | 65 mg/mL | Y | ||
| 14789012707 | PHENOBARBITAL SODIUM | phenobarbital sodium | VIAL | 65 mg/mL | Y | ||
| 42494041501 | PHENOBARBITAL SODIUM | phenobarbital sodium | VIAL | 65 mg/mL | Y | ||
| 42494041503 | PHENOBARBITAL SODIUM | phenobarbital sodium | VIAL | 65 mg/mL | Y | ||
| 42494041525 | PHENOBARBITAL SODIUM | phenobarbital sodium | VIAL | 65 mg/mL | Y | ||
| 42494044101 | PHENOBARBITAL SODIUM | phenobarbital sodium | VIAL | 65 mg/mL | Y | ||
| 42494044125 | PHENOBARBITAL SODIUM | phenobarbital sodium | VIAL | 65 mg/mL | Y | ||
| 63304067980 | SECONAL SODIUM | secobarbital sodium | CAPSULE | 100 mg | Y |