Neuromuscular
Skeletal Muscle Relaxants

Brand/Generic Name
(Generics in italics)		 Dosage/Strength Status Restrictions Notes Cost Sharing
Amrix
Cyclobenzaprine HCl		 Capsule SR 24 HR   notreimb.gif (545 bytes)     N/A
Flexeril generic.gif (400 bytes)
Cyclobenzaprine HCl		 Tab - 10 mg   approved.gif (510 bytes)     Tier 2
Flexeril generic.gif (400 bytes)
Cyclobenzaprine HCl		 Tab - 5 mg   approved.gif (510 bytes)     Tier 2
Lioresal generic.gif (400 bytes)
Baclofen		   approved.gif (510 bytes)     Tier 2
Norflex generic.gif (400 bytes)
Orphenadrine Citrate		   nonform.gif (510 bytes)     Tier 3
Norgesic generic.gif (400 bytes)
Orphenadrine-Aspirin-Caffeine		   nonform.gif (510 bytes)     Tier 3
Norgesic Forte generic.gif (400 bytes)
Orphenadrine-Aspirin-Caffeine		   nonform.gif (510 bytes)     Tier 3
Parafon Forte DSC generic.gif (400 bytes)
Chlorzoxazone		   nonform.gif (510 bytes)     Tier 3
Robaxin generic.gif (400 bytes)
Methocarbamol		   approved.gif (510 bytes)     Tier 2
Skelaxin
Metaxalone		   nonform.gif (510 bytes)     Tier 3
Soma generic.gif (400 bytes)
Carisoprodol		 Tab - 350 mg   approved.gif (510 bytes)     Tier 2
Soma
Carisoprodol		 Tab - 250 mg   notreimb.gif (545 bytes)     N/A
Soma Compound generic.gif (400 bytes)
Carisoprodol-Aspirin		   approved.gif (510 bytes)     Tier 2
Soma Compound/Codeine generic.gif (400 bytes)
Carisoprodol-Aspirin-Codeine		 Tab - 200-325-16 mg   nonform.gif (510 bytes)     Tier 3
Zanaflex generic.gif (400 bytes)
TiZANidine HCl		 Tab   approved.gif (510 bytes)     Tier 2
Zanaflex
TiZANidine HCl		 Cap   notreimb.gif (545 bytes)     N/A

Key for Product(s) Listed Above
Formulary Non-Formulary Prior Authorization Not Reimbursed
Quantity Limit   Generic Available (Most Generics
Available at Tier 1)		 Step Therapy Notes

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