Antianginals

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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
ISOSORBIDE DINITRATE DILATRATE-SR CAPSULE ER Y    
ISOSORBIDE DINITRATE ISORDIL TABLET Y    
ISOSORBIDE DINITRATE ISORDIL TITRADOSE TABLET Y    
ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE TABLET Y    
ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE TABLET Y    
NITROGLYCERIN NITROGLYCERIN CAPSULE ER Y    
NITROGLYCERIN MINITRAN PATCH TD24 Y    
NITROGLYCERIN NITROGLYCERIN PATCH PATCH TD24 Y    
NITROGLYCERIN NITRO-DUR PATCH TD24 Y    
NITROGLYCERIN NITROGLYCERIN TAB SUBL Y    
NITROGLYCERIN NITROSTAT TAB SUBL Y    
ISOSORBIBE DINIT/HYDRALAZINE BIDIL TABLET N    
ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE TAB SUBL N    
ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE TABLET ER N    
ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE ER TAB ER 24H N    
NITROGLYCERIN NITRO-BID OINT. (G) N    
NITROGLYCERIN GONITRO POWD PACK N    
NITROGLYCERIN NITROGLYCERIN SPRAY N    
NITROGLYCERIN NITROLINGUAL SPRAY N    
NITROGLYCERIN NITROMIST SPRAY N    
RANOLAZINE RANEXA TAB ER 12H N   Aug 30, 2012