Antianginals
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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| isosorbide dinitrate | ISOSORBIDE DINITRATE | TABLET | Y | N | ||
| isosorbide mononitrate | ISOSORBIDE MONONITRATE | TABLET | Y | N | ||
| nitroglycerin | NITRO-DUR | PATCH TD24 | Y | N | ||
| nitroglycerin | NITROGLYCERIN PATCH | PATCH TD24 | Y | N | ||
| nitroglycerin | NITROSTAT | TAB SUBL | Y | N | ||
| nitroglycerin | NITROGLYCERIN | TAB SUBL | Y | N | ||
| isosorbide dinit/hydralazine | BIDIL | TABLET | N | N | ||
| isosorbide dinit/hydralazine | ISOSORBIDE DINIT-HYDRALAZINE | TABLET | N | N | ||
| isosorbide dinitrate | ISOSORBIDE DINITRATE | TAB SUBL | N | N | ||
| isosorbide mononitrate | ISOSORBIDE MONONITRATE | TAB ER 24H | N | N | ||
| isosorbide mononitrate | ISOSORBIDE MONONITRATE ER | TAB ER 24H | N | N | ||
| nitroglycerin | NITROGLYCERIN | OINT. (G) | N | N | ||
| nitroglycerin | NITRO-BID | OINT. (G) | N | N | ||
| nitroglycerin | GONITRO | POWD PACK | N | N | ||
| nitroglycerin | NITROGLYCERIN | SPRAY | N | N | ||
| nitroglycerin | NITROLINGUAL | SPRAY | N | N | ||
| ranolazine | RANOLAZINE ER | TAB ER 12H | N | N |