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 | New Drug Evaluation |
|---|---|---|---|---|---|
| ivabradine HCl | CORLANOR | SOLUTION | N | PA Document | |
| ivabradine HCl | IVABRADINE HCL | TABLET | N | PA Document | |
| ivabradine HCl | CORLANOR | TABLET | N | PA Document | Nov 19, 2015 |
| nimodipine | NYMALIZE | SOLUTION | N | ||
| nimodipine | NYMALIZE | SYRINGE | N | ||
| adenosine | ADENOSINE | SYRINGE | |||
| adenosine | ADENOSINE | VIAL | |||
| alprostadil | PROSTIN VR PEDIATRIC | AMPUL | |||
| alteplase | CATHFLO ACTIVASE | VIAL | |||
| alteplase | ACTIVASE | VIAL | |||
| amiodarone HCl | AMIODARONE HCL | SYRINGE | |||
| amiodarone HCl | PACERONE | TABLET | |||
| amiodarone HCl | AMIODARONE HCL | TABLET | |||
| amiodarone HCl | AMIODARONE HCL | VIAL | |||
| amiodarone in dextrose,iso-osm | NEXTERONE | PLAST. BAG | |||
| anistreplase | EMINASE | VIAL | |||
| cardioplegic solution no.1 | PLEGISOL | PLST BG PR | |||
| cardioplegic solution no.1 | CARDIOPLEGIC | PLST BG PR | |||
| clevidipine butyrate | CLEVIPREX | VIAL | |||
| defibrotide sodium | DEFITELIO | VIAL | |||
| diltiazem HCl | DILTIAZEM HCL | SYRINGE | |||
| diltiazem HCl | DILTIAZEM HCL | VIAL | |||
| diltiazem HCl | CARDIZEM | VIAL | |||
| diltiazem HCl | DILTIAZEM HCL | VIAL PORT | |||
| disopyramide phosphate | DISOPYRAMIDE PHOSPHATE | CAPSULE | |||
| disopyramide phosphate | NORPACE | CAPSULE | |||
| disopyramide phosphate | NORPACE CR | CAPSULE ER | |||
| dobutamine HCl | DOBUTAMINE HCL | VIAL | |||
| dobutamine HCl in dextrose 5 % | DOBUTAMINE HCL IN DEXTROSE | IV SOLN | |||
| dobutamine HCl in dextrose 5 % | DOBUTAMINE HCL-D5W | IV SOLN | |||
| dofetilide | DOFETILIDE | CAPSULE | |||
| dofetilide | TIKOSYN | CAPSULE | |||
| dronedarone HCl | MULTAQ | TABLET | |||
| esmolol HCl | BREVIBLOC | VIAL | |||
| esmolol HCl | ESMOLOL HCL | VIAL | |||
| esmolol HCl in sterile water | ESMOLOL HCL-WATER | IV SOLN | |||
| esmolol in sodium chloride,iso | ESMOLOL HCL-SODIUM CHLORIDE | IV SOLN | |||
| esmolol in sodium chloride,iso | BREVIBLOC | IV SOLN | |||
| flecainide acetate | FLECAINIDE ACETATE | TABLET | |||
| ibuprofen lysine/PF | NEOPROFEN | VIAL | |||
| ibuprofen lysine/PF | IBUPROFEN LYSINE | VIAL | |||
| ibutilide fumarate | IBUTILIDE FUMARATE | VIAL | |||
| ibutilide fumarate | CORVERT | VIAL | |||
| indomethacin sodium | INDOMETHACIN | VIAL | |||
| labetalol HCl | LABETALOL HCL | CARTRIDGE | |||
| labetalol HCl | LABETALOL HCL | SYRINGE | |||
| labetalol HCl | TRANDATE | VIAL | |||
| labetalol HCl | LABETALOL HCL | VIAL | |||
| lidocaine HCl/D5W | LIDOCAINE HCL IN 5% DEXTROSE | IV SOLN | |||
| lidocaine HCl/dextrose 5 %/PF | LIDOCAINE HCL IN 5% DEXTROSE | IV SOLN | |||
| lidocaine HCl/PF | LIDOCAINE HCL | SYRINGE | |||
| lidocaine HCl/PF | LIDOCAINE HCL | VIAL | |||
| mavacamten | CAMZYOS | CAPSULE | PA Document | ||
| metoprolol tartrate | METOPROLOL TARTRATE | CARTRIDGE | |||
| metoprolol tartrate | METOPROLOL TARTRATE | VIAL | |||
| mexiletine HCl | MEXILETINE HCL | CAPSULE | |||
| milrinone lactate | MILRINONE LACTATE | VIAL | |||
| milrinone lactate/D5W | MILRINONE IN 5% DEXTROSE | PIGGYBACK | |||
| moricizine HCl | ETHMOZINE | TABLET | |||
| nicardipine HCl | NICARDIPINE HCL | AMPUL | |||
| nicardipine HCl | NICARDIPINE HCL | VIAL | |||
| nicardipine in NaCl, iso-osm | NICARDIPINE HCL-0.9% NACL | PIGGYBACK | |||
| nicardipine in NaCl, iso-osm | CARDENE I.V. | PIGGYBACK | |||
| nimodipine | NIMOTOP | CAPSULE | |||
| nimodipine | NIMODIPINE | CAPSULE | |||
| nimodipine | NIMODIPINE | SOLUTION | |||
| pentoxifylline | PENTOXIFYLLINE | TABLET ER | |||
| phenoxybenzamine HCl | PHENOXYBENZAMINE HCL | CAPSULE | |||
| phentolamine mesylate | PHENTOLAMINE MESYLATE | VIAL | |||
| procainamide HCl | PRONESTYL | CAPSULE | |||
| procainamide HCl | PROCAINAMIDE HCL | SYRINGE | |||
| procainamide HCl | PROCANBID | TAB ER 12H | |||
| procainamide HCl | PROCAINAMIDE HCL | VIAL | |||
| propafenone HCl | RYTHMOL SR | CAP ER 12H | |||
| propafenone HCl | PROPAFENONE HCL ER | CAP ER 12H | |||
| propafenone HCl | PROPAFENONE HCL | TABLET | |||
| propranolol HCl | PROPRANOLOL HCL | VIAL | |||
| quinidine gluconate | QUINIDINE GLUCONATE | TABLET ER | |||
| quinidine sulfate | QUINIDINE SULFATE | TABLET | |||
| reteplase | RETAVASE | VIAL | |||
| sodium tetradecyl sulfate | SOTRADECOL | VIAL | |||
| sodium tetradecyl sulfate | SODIUM TETRADECYL SULFATE | VIAL | |||
| tenecteplase | TNKASE | VIAL | |||
| verapamil HCl | VERAPAMIL HCL | AMPUL | |||
| verapamil HCl | VERAPAMIL HCL | SYRINGE | |||
| verapamil HCl | VERAPAMIL HCL | VIAL |