Calcium Channel Blockers - Non-Dihydropyridine, Oral
PDL Reference Documents
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.
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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| diltiazem HCl | CARTIA XT | CAP ER 24H | Y | N | ||
| diltiazem HCl | DILT-XR | CAP ER DEG | Y | N | ||
| diltiazem HCl | DILTIAZEM 24HR ER | CAP SA 24H | Y | N | ||
| verapamil HCl | VERAPAMIL HCL | CAP24H PEL | Y | N | ||
| verapamil HCl | VERAPAMIL SR | CAP24H PEL | Y | N | ||
| verapamil HCl | VERAPAMIL HCL | TABLET | Y | N | ||
| verapamil HCl | VERAPAMIL ER | TABLET ER | Y | N | ||
| diltiazem HCl | DILTIAZEM 24HR ER (LA) | TAB ER 24H | N | N | ||
| verapamil HCl | VERELAN PM | CAP24H PCT | N | N |