Calcium Channel Blockers - Dihydropyridine, Oral
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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.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | New Drug Evaluation |
|---|---|---|---|---|---|
| amlodipine besylate | NORVASC | TABLET | Y | ||
| amlodipine besylate | AMLODIPINE BESYLATE | TABLET | Y | ||
| nicardipine HCl | NICARDIPINE HCL | CAPSULE | Y | ||
| nifedipine | NIFEDIPINE ER | TAB ER 24 | Y | ||
| nifedipine | PROCARDIA XL | TAB ER 24 | Y | ||
| nifedipine | NIFEDIPINE ER | TABLET ER | Y | ||
| amlodipine benzoate | KATERZIA | ORAL SUSP | N | ||
| amlodipine besylate | NORLIQVA | SOLUTION | N | ||
| felodipine | FELODIPINE ER | TAB ER 24H | N | ||
| isradipine | ISRADIPINE | CAPSULE | N | ||
| levamlodipine maleate | LEVAMLODIPINE MALEATE | TABLET | N | ||
| nifedipine | NIFEDIPINE | CAPSULE | N | ||
| nisoldipine | NISOLDIPINE | TAB ER 24H | N | ||
| nisoldipine | SULAR | TAB ER 24H | N | ||
| amlodipine besylate | AMLODIPINE BESYLATE | TABLET |