Cardiovascular Agents, Miscellaneous
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 |
|---|---|---|---|---|---|---|
| ivabradine HCl | CORLANOR | TABLET | N | Pharmacy PA | N | Nov 19, 2015 |
| nimodipine | NYMALIZE | SYRINGE | N | N | ||
| adenosine | ADENOSINE | SYRINGE | N | |||
| adenosine | ADENOSINE | VIAL | N | |||
| alprostadil | ALPROSTADIL | VIAL | N | |||
| alteplase | ACTIVASE | VIAL | N | |||
| amiodarone HCl | PACERONE | TABLET | N | |||
| amiodarone HCl | AMIODARONE HCL | TABLET | N | |||
| clevidipine butyrate | CLEVIPREX | VIAL | N | |||
| defibrotide sodium | DEFITELIO | VIAL | N | |||
| diltiazem HCl | DILTIAZEM HCL | VIAL | N | |||
| diltiazem HCl | CARDIZEM | VIAL | N | |||
| disopyramide phosphate | DISOPYRAMIDE PHOSPHATE | CAPSULE | N | |||
| disopyramide phosphate | NORPACE CR | CAPSULE ER | N | |||
| dobutamine HCl | DOBUTAMINE HCL | VIAL | N | |||
| dobutamine HCl in dextrose 5 % | DOBUTAMINE HCL IN DEXTROSE | IV SOLN | N | |||
| dofetilide | DOFETILIDE | CAPSULE | N | |||
| dronedarone HCl | MULTAQ | TABLET | N | |||
| esmolol HCl | ESMOLOL HCL | VIAL | N | |||
| esmolol HCl | BREVIBLOC | VIAL | N | |||
| esmolol in sodium chloride,iso | BREVIBLOC | IV SOLN | N | |||
| ethyl alcohol | DEHYDRATED ALCOHOL | AMPUL | N | |||
| ibuprofen lysine/PF | NEOPROFEN | VIAL | N | |||
| ibutilide fumarate | IBUTILIDE FUMARATE | VIAL | N | |||
| labetalol HCl | LABETALOL HCL | CARTRIDGE | N | |||
| labetalol HCl | LABETALOL HCL | SYRINGE | N | |||
| labetalol HCl | TRANDATE | VIAL | N | |||
| lidocaine HCl/dextrose 5 %/PF | LIDOCAINE HCL IN 5% DEXTROSE | IV SOLN | N | |||
| lidocaine HCl/PF | LIDOCAINE HCL | VIAL | N | |||
| moricizine HCl | ETHMOZINE | TABLET | N | |||
| nicardipine HCl | NICARDIPINE HCL | VIAL | N | |||
| nicardipine in NaCl, iso-osm | NICARDIPINE HCL-0.9% NACL | PIGGYBACK | N | |||
| nimodipine | NIMOTOP | CAPSULE | N | |||
| phenoxybenzamine HCl | PHENOXYBENZAMINE HCL | CAPSULE | N | |||
| phentolamine mesylate | PHENTOLAMINE MESYLATE | VIAL | N | |||
| procainamide HCl | PRONESTYL | CAPSULE | N | |||
| procainamide HCl | PROCAINAMIDE HCL | SYRINGE | N | |||
| procainamide HCl | PROCAINAMIDE HCL | VIAL | N | |||
| quinidine gluconate | QUINIDINE GLUCONATE | TABLET ER | N | |||
| quinidine sulfate | QUINIDINE SULFATE | TABLET | N | |||
| sodium tetradecyl sulfate | SOTRADECOL | VIAL | N | |||
| sodium tetradecyl sulfate | SODIUM TETRADECYL SULFATE | VIAL | N | |||
| verapamil HCl | VERAPAMIL HCL | AMPUL | N | |||
| verapamil HCl | VERAPAMIL HCL | VIAL | N |