Calcium Channel Blockers - Dihydropyridine, 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
amlodipine besylate AMLODIPINE BESYLATE TABLET Y    
amlodipine besylate NORVASC TABLET Y    
nicardipine HCl NICARDIPINE HCL CAPSULE Y    
nifedipine NIFEDIPINE ER TAB ER 24 Y    
nifedipine PROCARDIA XL TAB ER 24 Y    
nifedipine NIFEDIPINE ER TABLET ER Y    
nifedipine AFEDITAB CR TABLET ER Y    
nifedipine ADALAT CC TABLET ER Y    
felodipine FELODIPINE ER TAB ER 24H N    
isradipine ISRADIPINE CAPSULE N    
nifedipine PROCARDIA CAPSULE N    
nifedipine NIFEDIPINE CAPSULE N    
nisoldipine SULAR TAB ER 24H N    
nisoldipine NISOLDIPINE TAB ER 24H N