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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 but eligible patients will encounter a co-pay at the pharmacy.
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
Current Drug Use Criteria New Drug Evaluation
isosorbide dinitrate DILATRATE-SR CAPSULE ER Y    
isosorbide dinitrate ISORDIL TABLET Y    
isosorbide dinitrate ISOSORBIDE DINITRATE TABLET Y    
isosorbide dinitrate ISORDIL TITRADOSE TABLET Y    
isosorbide mononitrate ISOSORBIDE MONONITRATE TABLET Y    
isosorbide mononitrate MONOKET TABLET Y    
nitroglycerin NITRO-DUR PATCH TD24 Y    
nitroglycerin MINITRAN PATCH TD24 Y    
nitroglycerin NITROGLYCERIN TAB SUBL Y    
nitroglycerin NITROSTAT TAB SUBL Y    
isosorbide dinit/hydralazine BIDIL TABLET N    
isosorbide dinitrate ISOSORBIDE DINITRATE TAB SUBL N    
isosorbide mononitrate ISOSORBIDE MONONITRATE TAB ER 24H N    
isosorbide mononitrate ISOSORBIDE MONONITRATE ER TAB ER 24H N    
nitroglycerin NITRO-BID OINT. (G) N    
nitroglycerin GONITRO POWD PACK N    
nitroglycerin NITROLINGUAL SPRAY N    
nitroglycerin NITROMIST SPRAY N    
nitroglycerin NITROGLYCERIN SPRAY N    
ranolazine RANEXA TAB ER 12H N   Aug 30, 2012