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