Cardiovascular Agents, Miscellaneous

← 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
IVABRADINE HCL CORLANOR TABLET N PA Document Nov 19, 2015
ADENOSINE ADENOSINE SYRINGE    
ADENOSINE ADENOCARD SYRINGE    
ADENOSINE ADENOSINE VIAL    
ALPROSTADIL PROSTIN VR PEDIATRIC AMPUL    
ALPROSTADIL ALPROSTADIL VIAL    
ALTEPLASE ACTIVASE VIAL    
ALTEPLASE CATHFLO ACTIVASE VIAL    
AMIODARONE HCL AMIODARONE HCL SYRINGE    
AMIODARONE HCL PACERONE TABLET    
AMIODARONE HCL AMIODARONE HCL TABLET    
AMIODARONE HCL AMIODARONE HCL VIAL    
AMIODARONE IN DEXTROSE,ISO-OSM NEXTERONE PLAST. BAG    
CARDIOPLEGIC SOLUTION NO.1 PLEGISOL PLST BG PF    
CARDIOPLEGIC SOLUTION NO.1 CARDIOPLEGIC PLST BG PF    
CLEVIDIPINE BUTYRATE CLEVIPREX VIAL    
DEFIBROTIDE SODIUM DEFITELIO VIAL    
DILTIAZEM HCL DILTIAZEM HCL VIAL    
DILTIAZEM HCL DILTIAZEM HCL VIAL PORT    
DISOPYRAMIDE PHOSPHATE NORPACE CAPSULE    
DISOPYRAMIDE PHOSPHATE DISOPYRAMIDE PHOSPHATE CAPSULE    
DISOPYRAMIDE PHOSPHATE NORPACE CR CAPSULE ER    
DOBUTAMINE HCL DOBUTAMINE HCL VIAL    
DOBUTAMINE HCL IN DEXTROSE 5 % DOBUTAMINE HCL IN DEXTROSE IV SOLN    
DOFETILIDE TIKOSYN CAPSULE    
DOFETILIDE DOFETILIDE CAPSULE    
DRONEDARONE HCL MULTAQ TABLET    
ESMOLOL HCL ESMOLOL HCL VIAL    
ESMOLOL HCL BREVIBLOC VIAL    
ESMOLOL IN SODIUM CHLORIDE,ISO BREVIBLOC IV SOLN    
FLECAINIDE ACETATE FLECAINIDE ACETATE TABLET    
IBUPROFEN LYSINE/PF NEOPROFEN VIAL    
IBUPROFEN LYSINE/PF IBUPROFEN LYSINE VIAL    
IBUTILIDE FUMARATE IBUTILIDE FUMARATE VIAL    
IBUTILIDE FUMARATE CORVERT VIAL    
INDOMETHACIN SODIUM INDOMETHACIN VIAL    
LABETALOL HCL LABETALOL HCL SYRINGE    
LABETALOL HCL LABETALOL HCL VIAL    
LIDOCAINE HCL/DEXTROSE 5 %/PF LIDOCAINE HCL IN 5% DEXTROSE IV SOLN    
LIDOCAINE HCL/PF XYLOCAINE IV AMPUL    
LIDOCAINE HCL/PF LIDOCAINE HCL SYRINGE    
LIDOCAINE HCL/PF LIDOCAINE HCL VIAL    
METOPROLOL TARTRATE METOPROLOL TARTRATE AMPUL    
METOPROLOL TARTRATE METOPROLOL TARTRATE SYRINGE    
METOPROLOL TARTRATE METOPROLOL TARTRATE VIAL    
MEXILETINE HCL MEXILETINE HCL CAPSULE    
MILRINONE LACTATE MILRINONE LACTATE VIAL    
MILRINONE LACTATE/D5W MILRINONE IN 5% DEXTROSE PIGGYBACK    
NESIRITIDE NATRECOR VIAL    
NICARDIPINE HCL NICARDIPINE HCL AMPUL    
NICARDIPINE HCL NICARDIPINE HCL VIAL    
NICARDIPINE IN DEXTROSE,ISO-OS CARDENE I.V. PIGGYBACK    
NICARDIPINE IN NACL, ISO-OSM CARDENE I.V. PIGGYBACK    
NIMODIPINE NIMODIPINE CAPSULE    
NIMODIPINE NYMALIZE SOLUTION    
PENTOXIFYLLINE PENTOXIFYLLINE TABLET ER    
PHENOXYBENZAMINE HCL PHENOXYBENZAMINE HCL CAPSULE    
PHENOXYBENZAMINE HCL DIBENZYLINE CAPSULE    
PHENTOLAMINE MESYLATE PHENTOLAMINE MESYLATE VIAL    
POLIDOCANOL ASCLERA AMPUL    
PROCAINAMIDE HCL PROCAINAMIDE HCL VIAL    
PROPAFENONE HCL PROPAFENONE HCL ER CAP ER 12H    
PROPAFENONE HCL RYTHMOL SR CAP ER 12H    
PROPAFENONE HCL PROPAFENONE HCL TABLET    
PROPRANOLOL HCL PROPRANOLOL HCL VIAL    
QUINIDINE GLUCONATE QUINIDINE GLUCONATE TABLET ER    
QUINIDINE GLUCONATE QUINIDINE GLUCONATE VIAL    
QUINIDINE SULFATE QUINIDINE SULFATE TABLET    
SODIUM TETRADECYL SULFATE SOTRADECOL VIAL    
TENECTEPLASE TNKASE KIT    
VERAPAMIL HCL VERAPAMIL HCL AMPUL    
VERAPAMIL HCL VERAPAMIL HCL SYRINGE    
VERAPAMIL HCL VERAPAMIL HCL VIAL