Beta-Blockers, Oral

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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 but eligible patients will encounter a co-pay at the pharmacy.
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
ACEBUTOLOL HCL ACEBUTOLOL HCL CAPSULE Y    
ATENOLOL TENORMIN TABLET Y    
ATENOLOL ATENOLOL TABLET Y    
CARVEDILOL CARVEDILOL TABLET Y    
CARVEDILOL COREG TABLET Y    
LABETALOL HCL LABETALOL HCL TABLET Y    
METOPROLOL SUCCINATE TOPROL XL TAB ER 24H Y    
METOPROLOL SUCCINATE METOPROLOL SUCCINATE TAB ER 24H Y    
METOPROLOL TARTRATE METOPROLOL TARTRATE TABLET Y    
METOPROLOL TARTRATE LOPRESSOR TABLET Y    
PROPRANOLOL HCL PROPRANOLOL HCL TABLET Y    
BETAXOLOL HCL BETAXOLOL HCL TABLET N    
BISOPROLOL FUMARATE BISOPROLOL FUMARATE TABLET N    
CARVEDILOL PHOSPHATE COREG CR CPMP 24HR N    
NADOLOL CORGARD TABLET N    
NADOLOL NADOLOL TABLET N    
NEBIVOLOL HCL BYSTOLIC TABLET N    
PINDOLOL PINDOLOL TABLET N    
PROPRANOLOL HCL INDERAL XL CAP ER 24H N    
PROPRANOLOL HCL INNOPRAN XL CAP ER 24H N    
PROPRANOLOL HCL INDERAL LA CAP SA 24H N    
PROPRANOLOL HCL PROPRANOLOL HCL ER CAP SA 24H N    
PROPRANOLOL HCL HEMANGEOL SOLUTION N    
PROPRANOLOL HCL PROPRANOLOL HCL SOLUTION N    
SOTALOL HCL SOTYLIZE SOLUTION N    
SOTALOL HCL BETAPACE AF TABLET N    
SOTALOL HCL SORINE TABLET N    
SOTALOL HCL SOTALOL TABLET N    
SOTALOL HCL SOTALOL AF TABLET N    
SOTALOL HCL BETAPACE TABLET N    
TIMOLOL MALEATE TIMOLOL MALEATE TABLET N