Vasodilators: Coronary

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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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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
00517480510 NITROGLYCERIN nitroglycerin VIAL 5 mg/mL Y N  
00517481001 NITROGLYCERIN nitroglycerin VIAL 50 mg/10 mL (5 mg/mL) Y N  
00517481025 NITROGLYCERIN nitroglycerin VIAL 50 mg/10 mL (5 mg/mL) Y N  
00338105102 NITROGLYCERIN IN D5W nitroglycerin in 5 % dextrose INFUS. BTL 100 mg/250 mL (0.4 mg/mL) Y N  
00338104702 NITROGLYCERIN IN D5W nitroglycerin in 5 % dextrose INFUS. BTL 25 mg/250 mL (0.1 mg/mL) Y N  
00338104902 NITROGLYCERIN IN D5W nitroglycerin in 5 % dextrose INFUS. BTL 50 mg/250 mL (0.2 mg/mL) Y N  
00006503001 VERQUVO vericiguat TABLET 10 mg Y N Pharmacy PA
00006503002 VERQUVO vericiguat TABLET 10 mg Y N Pharmacy PA
00006503003 VERQUVO vericiguat TABLET 10 mg Y N Pharmacy PA
00006503004 VERQUVO vericiguat TABLET 10 mg Y N Pharmacy PA
00006502801 VERQUVO vericiguat TABLET 2.5 mg Y N Pharmacy PA
00006502802 VERQUVO vericiguat TABLET 2.5 mg Y N Pharmacy PA
00006502803 VERQUVO vericiguat TABLET 2.5 mg Y N Pharmacy PA
00006502804 VERQUVO vericiguat TABLET 2.5 mg Y N Pharmacy PA
00006502901 VERQUVO vericiguat TABLET 5 mg Y N Pharmacy PA
00006502902 VERQUVO vericiguat TABLET 5 mg Y N Pharmacy PA
00006502903 VERQUVO vericiguat TABLET 5 mg Y N Pharmacy PA
00006502904 VERQUVO vericiguat TABLET 5 mg Y N Pharmacy PA
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