Calcium Channel Blockers - Non-Dihydropyridine, Oral
PDL Reference Documents
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 & Updates |
|---|---|---|---|---|---|
| diltiazem HCl | DILTIAZEM 12HR ER | CAP ER 12H | Y | ||
| diltiazem HCl | DILTIAZEM HCL | CAP ER 12H | Y | ||
| diltiazem HCl | CARTIA XT | CAP ER 24H | Y | ||
| diltiazem HCl | CARDIZEM CD | CAP ER 24H | Y | ||
| diltiazem HCl | DILTIAZEM 24HR ER (CD) | CAP ER 24H | Y | ||
| diltiazem HCl | DILT-XR | CAP ER DEG | Y | ||
| diltiazem HCl | DILTIAZEM 24HR ER (XR) | CAP ER DEG | Y | ||
| diltiazem HCl | TIADYLT ER | CAP SA 24H | Y | ||
| diltiazem HCl | TIAZAC | CAP SA 24H | Y | ||
| diltiazem HCl | DILTIAZEM 24HR ER | CAP SA 24H | Y | ||
| diltiazem HCl | CARDIZEM | TABLET | Y | ||
| diltiazem HCl | DILTIAZEM HCL | TABLET | Y | ||
| verapamil HCl | VERAPAMIL SR | CAP24H PEL | Y | ||
| verapamil HCl | VERAPAMIL ER | CAP24H PEL | Y | ||
| verapamil HCl | VERAPAMIL HCL | CAP24H PEL | Y | ||
| verapamil HCl | VERAPAMIL HCL | TABLET | Y | ||
| verapamil HCl | VERAPAMIL ER | TABLET ER | Y | ||
| diltiazem HCl | MATZIM LA | TAB ER 24H | N | ||
| diltiazem HCl | CARDIZEM LA | TAB ER 24H | N | ||
| diltiazem HCl | DILTIAZEM 24HR ER (LA) | TAB ER 24H | N | ||
| verapamil HCl | VERELAN PM | CAP24H PCT | N | ||
| verapamil HCl | VERAPAMIL ER PM | CAP24H PCT | N |