Cardiovascular Agents, Miscellaneous

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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.

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Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria Carveout
‐ Bill FFS		 New Drug Evaluation & Updates
ivabradine HCl CORLANOR SOLUTION N Pharmacy PA N  
ivabradine HCl CORLANOR TABLET N Pharmacy PA N Nov 19, 2015
ivabradine HCl IVABRADINE HCL TABLET N Pharmacy PA N  
nimodipine NYMALIZE SOLUTION N   N  
nimodipine NYMALIZE SYRINGE N   N  
adenosine ADENOSINE SYRINGE   N  
adenosine ADENOSINE VIAL   N  
alprostadil PROSTIN VR PEDIATRIC AMPUL   N  
alprostadil ALPROSTADIL VIAL   N  
alteplase CATHFLO ACTIVASE VIAL   N  
alteplase ACTIVASE VIAL   N  
amiodarone HCl AMIODARONE HCL TABLET   N  
amiodarone HCl PACERONE TABLET   N  
amiodarone HCl AMIODARONE HCL VIAL   N  
amiodarone in dextrose,iso-osm NEXTERONE PLAST. BAG   N  
anistreplase EMINASE VIAL   N  
cardioplegic solution no.1 CARDIOPLEGIC PLST BG PR   N  
cardioplegic solution no.1 PLEGISOL PLST BG PR   N  
clevidipine butyrate CLEVIPREX VIAL   N  
defibrotide sodium DEFITELIO VIAL   N  
diltiazem HCl DILTIAZEM HCL SYRINGE   N  
diltiazem HCl CARDIZEM VIAL   N  
diltiazem HCl DILTIAZEM HCL VIAL   N  
diltiazem HCl DILTIAZEM HCL VIAL PORT   N  
diltiazem HCl in NaCl,iso-osm DILTIAZEM HCL-NACL PLAST. BAG   N  
disopyramide phosphate NORPACE CAPSULE   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-D5W IV SOLN   N  
dobutamine HCl in dextrose 5 % DOBUTAMINE HCL IN DEXTROSE IV SOLN   N  
dofetilide DOFETILIDE CAPSULE   N  
dofetilide TIKOSYN CAPSULE   N  
dronedarone HCl MULTAQ TABLET   N  
esmolol HCl ESMOLOL HCL VIAL   N  
esmolol HCl BREVIBLOC VIAL   N  
esmolol HCl in sterile water ESMOLOL HCL-WATER IV SOLN   N  
esmolol in sodium chloride,iso ESMOLOL HCL-SODIUM CHLORIDE IV SOLN   N  
esmolol in sodium chloride,iso BREVIBLOC IV SOLN   N  
ethyl alcohol DEHYDRATED ALCOHOL AMPUL   N  
ethyl alcohol DEHYDRATED ALCOHOL VIAL   N  
flecainide acetate FLECAINIDE ACETATE TABLET   N  
ibuprofen lysine/PF IBUPROFEN LYSINE VIAL   N  
ibuprofen lysine/PF NEOPROFEN VIAL   N  
ibutilide fumarate CORVERT VIAL   N  
ibutilide fumarate IBUTILIDE FUMARATE VIAL   N  
indomethacin sodium INDOMETHACIN VIAL   N  
labetalol HCl LABETALOL HCL CARTRIDGE   N  
labetalol HCl LABETALOL HCL SYRINGE   N  
labetalol HCl TRANDATE VIAL   N  
labetalol HCl LABETALOL HCL VIAL   N  
lidocaine HCl/D5W LIDOCAINE HCL IN 5% DEXTROSE IV SOLN   N  
lidocaine HCl/dextrose 5 %/PF LIDOCAINE HCL IN 5% DEXTROSE IV SOLN   N  
lidocaine HCl/PF LIDOCAINE HCL SYRINGE   N  
lidocaine HCl/PF LIDOCAINE HCL VIAL   N  
metoprolol tartrate METOPROLOL TARTRATE CARTRIDGE   N  
metoprolol tartrate METOPROLOL TARTRATE VIAL   N  
mexiletine HCl MEXILETINE HCL CAPSULE   N  
milrinone lactate MILRINONE LACTATE VIAL   N  
milrinone lactate/D5W MILRINONE IN 5% DEXTROSE PIGGYBACK   N  
moricizine HCl ETHMOZINE TABLET   N  
nicardipine HCl NICARDIPINE HCL AMPUL   N  
nicardipine HCl NICARDIPINE HCL VIAL   N  
nicardipine in NaCl, iso-osm NICARDIPINE HCL-NACL PIGGYBACK   N  
nicardipine in NaCl, iso-osm CARDENE I.V. PIGGYBACK   N  
nicardipine in NaCl, iso-osm NICARDIPINE HCL-0.9% NACL PIGGYBACK   N  
nimodipine NIMODIPINE CAPSULE   N  
nimodipine NIMOTOP CAPSULE   N  
nimodipine NIMODIPINE SOLUTION   N  
pentoxifylline PENTOXIFYLLINE TABLET ER   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 PROCANBID TAB ER 12H   N  
procainamide HCl PROCAINAMIDE HCL VIAL   N  
propafenone HCl PROPAFENONE HCL ER CAP ER 12H   N  
propafenone HCl PROPAFENONE HCL TABLET   N  
propranolol HCl PROPRANOLOL 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  
tenecteplase TNKASE VIAL   N  
verapamil HCl VERAPAMIL HCL AMPUL   N  
verapamil HCl VERAPAMIL HCL SYRINGE   N  
verapamil HCl VERAPAMIL HCL VIAL   N  
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