Beta-Blockers, 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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| atenolol | ATENOLOL | TABLET | Y | N | ||
| labetalol HCl | LABETALOL HCL | TABLET | Y | N | ||
| metoprolol succinate | METOPROLOL SUCCINATE | TAB ER 24H | Y | N | ||
| nadolol | NADOLOL | TABLET | Y | N | ||
| propranolol HCl | PROPRANOLOL HCL | TABLET | Y | N | ||
| bisoprolol fumarate | BISOPROLOL FUMARATE | TABLET | N | N | ||
| carvedilol phosphate | CARVEDILOL ER | CPMP 24HR | N | N | ||
| labetalol HCl | LABETALOL HCL | TABLET | N | N | ||
| metoprolol succinate | KAPSPARGO SPRINKLE | CAP SPR 24 | N | N | ||
| metoprolol tartrate | LOPRESSOR | SOLUTION | N | N | ||
| propranolol HCl | INDERAL XL | CAP ER 24H | N | N | ||
| propranolol HCl | HEMANGEOL | SOLUTION | N | N | ||
| sotalol HCl | BETAPACE | TABLET | N | N | ||
| sotalol HCl | BETAPACE AF | TABLET | N | N | ||
| sotalol HCl | SOTALOL AF | TABLET | N | N | ||
| timolol maleate | TIMOLOL MALEATE | TABLET | N | N | ||
| timolol maleate | BLOCADREN | TABLET | N | N |