Other Hypotensives

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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
NEBIVOLOL HCL/VALSARTAN BYVALSON TABLET N    
CLONIDINE CLONIDINE PATCH TDWK    
CLONIDINE CATAPRES-TTS 3 PATCH TDWK    
CLONIDINE CATAPRES-TTS 2 PATCH TDWK    
CLONIDINE CATAPRES-TTS 1 PATCH TDWK    
CLONIDINE HCL CATAPRES TABLET    
CLONIDINE HCL CLONIDINE HCL TABLET    
ENALAPRILAT DIHYDRATE ENALAPRILAT VIAL    
FENOLDOPAM MESYLATE CORLOPAM AMPUL    
GUANFACINE HCL GUANFACINE HCL TABLET    
HYDRALAZINE HCL HYDRALAZINE HCL TABLET    
HYDRALAZINE HCL HYDRALAZINE HCL VIAL    
MECAMYLAMINE HCL VECAMYL TABLET    
METHYLDOPA METHYLDOPA TABLET    
METHYLDOPA/HYDROCHLOROTHIAZIDE METHYLDOPA-HYDROCHLOROTHIAZIDE TABLET    
METYROSINE DEMSER CAPSULE    
MINOXIDIL MINOXIDIL TABLET    
NITROPRUSSIDE IN 0.9% NACL NIPRIDE RTU VIAL    
NITROPRUSSIDE SODIUM NITROPRESS VIAL    
NITROPRUSSIDE SODIUM SODIUM NITROPRUSSIDE VIAL    
PRAZOSIN HCL PRAZOSIN HCL CAPSULE    
PRAZOSIN HCL MINIPRESS CAPSULE