Calcium Channel Blockers - Non-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
DILTIAZEM HCL DILTIAZEM 12HR ER CAP ER 12H Y    
DILTIAZEM HCL CARTIA XT CAP ER 24H Y    
DILTIAZEM HCL DILTIAZEM 24HR CD CAP ER 24H Y    
DILTIAZEM HCL DILTIAZEM 24HR ER CAP ER 24H Y    
DILTIAZEM HCL CARDIZEM CD CAP ER 24H Y    
DILTIAZEM HCL DILTIAZEM ER CAP ER DEG Y    
DILTIAZEM HCL DILT-XR CAP ER DEG Y    
DILTIAZEM HCL DILTIAZEM 24HR ER CAP SA 24H Y    
DILTIAZEM HCL TAZTIA XT CAP SA 24H Y    
DILTIAZEM HCL TIAZAC CAP SA 24H Y    
DILTIAZEM HCL DILTIAZEM HCL TABLET Y    
DILTIAZEM HCL CARDIZEM TABLET Y    
VERAPAMIL HCL VERAPAMIL ER CAP24H PEL Y    
VERAPAMIL HCL VERAPAMIL HCL CAP24H PEL Y    
VERAPAMIL HCL VERAPAMIL SR CAP24H PEL Y    
VERAPAMIL HCL VERELAN CAP24H PEL Y    
VERAPAMIL HCL CALAN TABLET Y    
VERAPAMIL HCL VERAPAMIL HCL TABLET Y    
VERAPAMIL HCL VERAPAMIL ER TABLET ER Y    
VERAPAMIL HCL CALAN SR TABLET ER Y    
DILTIAZEM HCL CARDIZEM LA TAB ER 24H N    
DILTIAZEM HCL DILTIAZEM 24HR ER TAB ER 24H N    
DILTIAZEM HCL MATZIM LA TAB ER 24H N    
VERAPAMIL HCL VERAPAMIL ER PM CAP24H PCT N    
VERAPAMIL HCL VERELAN PM CAP24H PCT N