Cardiovascular Agents

Brand/Generic Name (Generics in italics)

Dosage/Strength

Status

Restrictions

Notes

Copayment Tier

Cardizem CD Diltiazem HCl Coated Beads Capsule SR 24 HR - 120 mg     N/A Cardizem CD Diltiazem HCl Coated Beads Capsule SR 24 HR - 180 mg     N/A Cardizem CD Diltiazem HCl Coated Beads Capsule SR 24 HR - 240 mg     N/A Cardizem CD Diltiazem HCl Coated Beads Capsule SR 24 HR - 300 mg     N/A Cardizem CD Diltiazem HCl Coated Beads Capsule SR 24 HR - 360 mg     N/A Cardizem LA Diltiazem HCl Coated Beads     N/A Cartia XT Diltiazem HCl Coated Beads     Tier 1 Cartia XT Diltiazem HCl Coated Beads Capsule SR 24 HR - 120 mg     Tier 1 Cartia XT Diltiazem HCl Coated Beads Capsule SR 24 HR - 180 mg     Tier 1 Cartia XT Diltiazem HCl Coated Beads Capsule SR 24 HR - 240 mg     Tier 1 Cartia XT Diltiazem HCl Coated Beads Capsule SR 24 HR - 300 mg     Tier 1 Diltiazem HCl Coated Beads Diltiazem HCl Coated Beads Capsule SR 24 HR - 300 mg     Tier 1

Key for Product(s) Listed Above

Formulary Non-Covered Medications that have Covered Alternatives Prior Authorization Not Covered Quantity Limit Generic is Formulary, Brand is Non-Formulary Step Therapy Notes Specialty Medications Tier 1 Generic Drugs Tier 2 Preferred Brand Name Drugs Tier 3 Non-Preferred Brand-Name Drugs Tier 4 Specialty Drugs - Tier 3 Copay

© 2006 MediMedia USA, Inc. All Rights Reserved.   Last Updated: 07/12/2010