Tranquilizers, 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.
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.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Current Drug Use Criteria
81279012360 BUCAPSOL buspirone HCl CAPSULE 10 mg Y  
81279012460 BUCAPSOL buspirone HCl CAPSULE 15 mg Y  
81279012260 BUCAPSOL buspirone HCl CAPSULE 7.5 mg Y  
00093005401 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
00093005405 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
00378115001 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
00378115005 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
00904712161 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
16729020201 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
16729020216 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
23155002401 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
23155002405 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
24689090701 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
24689090705 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
29300024501 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
29300024505 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
42543074207 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
42806008401 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
42806008405 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
42806066301 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
42806066305 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
51079098601 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
51079098620 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
59651039101 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
59651039105 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
60505007900 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
60505007901 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
60687081201 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
60687081211 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
64380074206 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
64380074207 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
64380074208 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
68382018101 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
68382018105 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
69584009210 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
69584009250 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
72888006401 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
72888006405 BUSPIRONE HCL buspirone HCl TABLET 10 mg Y  
00093100301 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
00093100305 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
00378116505 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
00378116580 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
00378116591 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
00904689961 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
16729020301 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
16729020312 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
23155002501 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
23155002505 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
23155002506 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
23155002508 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
24689092101 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
24689092105 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
24689092106 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
29300024601 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
29300024605 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
29300024616 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
29300024618 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
29300047701 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
29300047705 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
29300047716 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
29300047718 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
42543074318 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
42806008501 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
42806008505 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
42806066401 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
42806066405 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
50268013511 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
50268013515 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
51079096001 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
51079096020 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
59651039201 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
59651039205 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
60505010300 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
60505010301 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
60687082301 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
60687082311 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
64380074303 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
64380074318 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
68382018201 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
68382018205 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
69584009306 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
69584009310 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
69584009350 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
72888006501 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
72888006505 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
72888006560 BUSPIRONE HCL buspirone HCl TABLET 15 mg Y  
00093520005 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
00093520006 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
00378117591 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
16729028912 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
23155009705 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
23155009706 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
24689093306 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
29300024705 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
29300024716 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
29300047805 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
29300047816 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
42543074403 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
42806008605 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
42806008660 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
42806066560 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
51079099401 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
51079099420 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
59651039360 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
64380074403 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
68382018305 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
68382018314 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
69117004302 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
69584009406 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
69584009450 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
72888006605 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
72888006660 BUSPIRONE HCL buspirone HCl TABLET 30 mg Y  
00093005301 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
00093005305 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
00378114001 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
00378114005 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
00904712261 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
16729020001 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
16729020016 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
23155002301 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
23155002305 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
24689078101 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
24689078105 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
29300024401 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
29300024405 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
42543074107 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
42806008201 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
42806008205 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
42806066201 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
42806066205 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
51079098501 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
51079098520 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
59651038901 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
59651038905 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
60505007800 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
60505007801 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
64380074106 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
64380074107 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
64380074108 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
68382018001 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
68382018005 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
69584009110 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
69584009150 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
72888006201 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
72888006205 BUSPIRONE HCL buspirone HCl TABLET 5 mg Y  
00378114501 BUSPIRONE HCL buspirone HCl TABLET 7.5 mg Y  
16729020101 BUSPIRONE HCL buspirone HCl TABLET 7.5 mg Y  
24689078501 BUSPIRONE HCL buspirone HCl TABLET 7.5 mg Y  
42543078706 BUSPIRONE HCL buspirone HCl TABLET 7.5 mg Y  
42806008301 BUSPIRONE HCL buspirone HCl TABLET 7.5 mg Y  
42806008305 BUSPIRONE HCL buspirone HCl TABLET 7.5 mg Y  
59651039001 BUSPIRONE HCL buspirone HCl TABLET 7.5 mg Y  
60687080111 BUSPIRONE HCL buspirone HCl TABLET 7.5 mg Y  
60687080121 BUSPIRONE HCL buspirone HCl TABLET 7.5 mg Y  
64380078706 BUSPIRONE HCL buspirone HCl TABLET 7.5 mg Y  
64380078707 BUSPIRONE HCL buspirone HCl TABLET 7.5 mg Y  
68382062301 BUSPIRONE HCL buspirone HCl TABLET 7.5 mg Y  
72888006301 BUSPIRONE HCL buspirone HCl TABLET 7.5 mg Y  
72888006305 BUSPIRONE HCL buspirone HCl TABLET 7.5 mg Y  
00409127303 DIAZEPAM diazepam CARTRIDGE 5 mg/mL Y  
00409127332 DIAZEPAM diazepam CARTRIDGE 5 mg/mL Y  
00641624401 DIAZEPAM diazepam SYRINGE 5 mg/mL Y  
00641624410 DIAZEPAM diazepam SYRINGE 5 mg/mL Y  
43598010610 DIAZEPAM diazepam SYRINGE 5 mg/mL Y  
43598010611 DIAZEPAM diazepam SYRINGE 5 mg/mL Y  
62332081102 DIAZEPAM diazepam SYRINGE 5 mg/mL Y  
62332081120 DIAZEPAM diazepam SYRINGE 5 mg/mL Y  
69339013603 DIAZEPAM diazepam SYRINGE 5 mg/mL Y  
69339013634 DIAZEPAM diazepam SYRINGE 5 mg/mL Y  
69339013693 DIAZEPAM diazepam SYRINGE 5 mg/mL Y  
69339013697 DIAZEPAM diazepam SYRINGE 5 mg/mL Y  
72572014001 DIAZEPAM diazepam SYRINGE 5 mg/mL Y  
72572014002 DIAZEPAM diazepam SYRINGE 5 mg/mL Y  
76045020400 DIAZEPAM diazepam SYRINGE 5 mg/mL Y  
76045020420 DIAZEPAM diazepam SYRINGE 5 mg/mL Y  
00004193306 VALIUM diazepam SYRINGE 5 mg/mL Y  
00409321311 DIAZEPAM diazepam VIAL 5 mg/mL Y  
00409321312 DIAZEPAM diazepam VIAL 5 mg/mL Y  
00641624301 DIAZEPAM diazepam VIAL 5 mg/mL Y  
00641624310 DIAZEPAM diazepam VIAL 5 mg/mL Y  
69339013701 DIAZEPAM diazepam VIAL 5 mg/mL Y  
69339013705 DIAZEPAM diazepam VIAL 5 mg/mL Y  
69339013791 DIAZEPAM diazepam VIAL 5 mg/mL Y  
69339013795 DIAZEPAM diazepam VIAL 5 mg/mL Y  
10019085021 DIZAC diazepam (in soybean oil) AMPUL 5 mg/mL Y  
00074226902 DROPERIDOL droperidol SYRINGE 2.5 mg/mL Y  
00143951401 DROPERIDOL droperidol VIAL 2.5 mg/mL Y  
00143951425 DROPERIDOL droperidol VIAL 2.5 mg/mL Y  
00143951501 DROPERIDOL droperidol VIAL 2.5 mg/mL Y  
00143951525 DROPERIDOL droperidol VIAL 2.5 mg/mL Y  
00517970201 DROPERIDOL droperidol VIAL 2.5 mg/mL Y  
00517970225 DROPERIDOL droperidol VIAL 2.5 mg/mL Y  
62332001931 MEPROBAMATE meprobamate TABLET 200 mg Y  
69097097407 MEPROBAMATE meprobamate TABLET 200 mg Y  
62332002031 MEPROBAMATE meprobamate TABLET 400 mg Y  
69097097507 MEPROBAMATE meprobamate TABLET 400 mg Y  
00037100103 MILTOWN meprobamate TABLET 400 mg Y  
00597002001 SERENTIL mesoridazine besylate TABLET 10 mg Y  
42806033801 MOLINDONE HCL molindone HCl TABLET 25 mg Y  
42806033601 MOLINDONE HCL molindone HCl TABLET 5 mg Y  
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