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 | SOLUTION | N | Pharmacy PA | ||
| ivabradine HCl | IVABRADINE HCL | TABLET | N | Pharmacy PA | ||
| ivabradine HCl | CORLANOR | TABLET | N | Pharmacy PA | Nov 19, 2015 | |
| adenosine | ADENOSINE | SYRINGE | ||||
| adenosine | ADENOSINE | VIAL | ||||
| alprostadil | PROSTIN VR PEDIATRIC | AMPUL | ||||
| alprostadil | ALPROSTADIL | VIAL | ||||
| alteplase | CATHFLO ACTIVASE | VIAL | ||||
| alteplase | ACTIVASE | VIAL | ||||
| 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 | CARDIZEM | VIAL | ||||
| diltiazem HCl | DILTIAZEM HCL | VIAL | ||||
| diltiazem HCl | DILTIAZEM HCL | VIAL PORT | ||||
| diltiazem HCl in NaCl,iso-osm | DILTIAZEM HCL-NACL | PLAST. BAG | ||||
| disopyramide phosphate | NORPACE | CAPSULE | ||||
| disopyramide phosphate | DISOPYRAMIDE PHOSPHATE | 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 | ||||
| ethyl alcohol | DEHYDRATED ALCOHOL | AMPUL | ||||
| ethyl alcohol | DEHYDRATED ALCOHOL | VIAL | ||||
| etripamil | CARDAMYST | SPRAY | ||||
| flecainide acetate | FLECAINIDE ACETATE | TABLET | ||||
| ibuprofen lysine/PF | IBUPROFEN LYSINE | VIAL | ||||
| ibuprofen lysine/PF | NEOPROFEN | 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 | ||||
| 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 HCl | CARDENE I.V. | VIAL | ||||
| nicardipine in NaCl, iso-osm | CARDENE I.V. | PIGGYBACK | ||||
| nicardipine in NaCl, iso-osm | NICARDIPINE HCL-0.9% NACL | PIGGYBACK | ||||
| nicardipine in NaCl, iso-osm | NICARDIPINE HCL-NACL | PIGGYBACK | ||||
| pentoxifylline | PENTOXIFYLLINE | TABLET ER | ||||
| phenoxybenzamine HCl | PHENOXYBENZAMINE HCL | CAPSULE | ||||
| phentolamine mesylate | PHENTOLAMINE MESYLATE | VIAL | ||||
| polidocanol | ASCLERA | AMPUL | ||||
| procainamide HCl | PRONESTYL | CAPSULE | ||||
| procainamide HCl | PROCAINAMIDE HCL | SYRINGE | ||||
| procainamide HCl | PROCANBID | TAB ER 12H | ||||
| procainamide HCl | PROCAINAMIDE HCL | VIAL | ||||
| 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 | ||||
| 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 |