Other Hypotensives
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 |
|---|---|---|---|---|---|
| clonidine HCl | CLONIDINE HCL ER | TAB ER 24H | N | ||
| clonidine HCl | NEXICLON XR | TAB ER 24H | N | ||
| macitentan/tadalafil | OPSYNVI | TABLET | N | ||
| sparsentan | FILSPARI | TABLET | N | PA Document | Dec 07, 2023 |
| aprocitentan | TRYVIO | TABLET | |||
| clonidine | CLONIDINE | PATCH TDWK | |||
| clonidine HCl | CLONIDINE HCL | TABLET | |||
| enalaprilat dihydrate | ENALAPRILAT | VIAL | |||
| guanfacine HCl | GUANFACINE HCL | TABLET | |||
| hydralazine HCl | HYDRALAZINE HCL | TABLET | |||
| hydralazine HCl | HYDRALAZINE HCL | VIAL | |||
| methyldopa | METHYLDOPA | TABLET | |||
| metyrosine | METYROSINE | CAPSULE | |||
| metyrosine | DEMSER | CAPSULE | |||
| minoxidil | MINOXIDIL | TABLET | |||
| nitroprusside in 0.9% NaCl | SODIUM NITROPRUSSIDE-0.9% NACL | VIAL | |||
| nitroprusside in 0.9% NaCl | NIPRIDE RTU | VIAL | |||
| nitroprusside sodium | NITROPRESS | KIT | |||
| nitroprusside sodium | SODIUM NITROPRUSSIDE | VIAL | |||
| prazosin HCl | PRAZOSIN HCL | CAPSULE | |||
| prazosin HCl | MINIPRESS | CAPSULE |