Beta-Blockers, Oral

← Back to Class List

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 SECTRAL CAPSULE Y    
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 METOPROLOL SUCCINATE TAB ER 24H Y    
metoprolol succinate TOPROL XL TAB ER 24H Y    
metoprolol tartrate LOPRESSOR TABLET Y    
metoprolol tartrate METOPROLOL TARTRATE TABLET Y    
propranolol HCl PROPRANOLOL HCL TABLET Y    
betaxolol HCl BETAXOLOL HCL TABLET N    
bisoprolol fumarate BISOPROLOL FUMARATE TABLET N    
carvedilol phosphate CARVEDILOL ER CPMP 24HR N    
carvedilol phosphate COREG CR CPMP 24HR N    
metoprolol succinate KAPSPARGO SPRINKLE CAP SPR 24 N    
nadolol CORGARD TABLET N    
nadolol NADOLOL TABLET N    
nebivolol HCl BYSTOLIC TABLET N    
penbutolol sulfate LEVATOL TABLET N    
pindolol PINDOLOL TABLET N    
propranolol HCl INNOPRAN XL CAP ER 24H N    
propranolol HCl INDERAL XL CAP ER 24H N    
propranolol HCl INDERAL LA CAP SA 24H N    
propranolol HCl PROPRANOLOL HCL ER CAP SA 24H N    
propranolol HCl PROPRANOLOL HCL SOLUTION N    
propranolol HCl HEMANGEOL SOLUTION N    
sotalol HCl SOTYLIZE SOLUTION N    
sotalol HCl SOTALOL TABLET N    
sotalol HCl SOTALOL AF TABLET N    
sotalol HCl SORINE TABLET N    
sotalol HCl BETAPACE AF TABLET N    
sotalol HCl BETAPACE TABLET N    
timolol maleate TIMOLOL MALEATE TABLET N    
timolol maleate BLOCADREN TABLET N