Drug Name Tier Notes metoprolol succinate er oral tablet extended release 24 hour 1 or 1b* metoprolol tartrate intravenous solution 5 mg/5ml 1 or 1a* metoprolol tartrate oral tablet 1 or 1a* nebivolol hcl oral tablet 2 *BETA BLOCKERS NON- SELECTIVE*** nadolol oral tablet 20 mg, 40 mg, 80 mg 1 or 1b* QL pindolol oral tablet 2 QL propranolol hcl er oral capsule extended release 24 hour 1 or 1b* QL propranolol hcl intravenous solution 1 or 1b* propranolol hcl oral solution 1 or 1b* QL propranolol hcl oral tablet 1 or 1b* QL sotalol hcl (af) oral tablet 2 QL sotalol hcl oral tablet 2 QL timolol maleate oral tablet 1 or 1b* QL *CALCIUM CHANNEL BLOCKERS* *CALCIUM CHANNEL BLOCKERS*** amlodipine besylate oral tablet 10 mg 1 or 1b* QL amlodipine besylate oral tablet 2.5 mg, 5 mg 1 or 1b* DO cartia xt oral capsule extended release 24 hour 120 mg 1 or 1b* DO cartia xt oral capsule extended release 24 hour 180 mg, 240 mg, 300 mg 1 or 1b* QL diltiazem hcl er beads oral capsule extended release 24 hour 120 mg 1 or 1b* DO diltiazem hcl er beads oral capsule extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg 1 or 1b* QL diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg 1 or 1b* DO Drug Name Tier Notes diltiazem hcl er coated beads oral capsule extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg 1 or 1b* QL diltiazem hcl er oral capsule extended release 12 hour 120 mg, 90 mg 1 or 1b* QL diltiazem hcl er oral capsule extended release 12 hour 60 mg 1 or 1b* DO diltiazem hcl er oral capsule extended release 24 hour 120 mg 1 or 1b* DO diltiazem hcl er oral capsule extended release 24 hour 180 mg, 240 mg 1 or 1b* QL diltiazem hcl er oral tablet extended release 24 hour 120 mg 1 or 1b* DO diltiazem hcl er oral tablet extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg 1 or 1b* QL diltiazem hcl intravenous solution 1 or 1b* diltiazem hcl oral tablet 120 mg, 90 mg 1 or 1b* QL diltiazem hcl oral tablet 30 mg, 60 mg 1 or 1b* DO dilt-xr oral capsule extended release 24 hour 120 mg 1 or 1b* DO dilt-xr oral capsule extended release 24 hour 180 mg, 240 mg 1 or 1b* QL felodipine er oral tablet extended release 24 hour 10 mg 1 or 1b* QL felodipine er oral tablet extended release 24 hour 2.5 mg, 5 mg 1 or 1b* DO isradipine oral capsule 2.5 mg 1 or 1b* DO isradipine oral capsule 5 mg 1 or 1b* QL levamlodipine maleate oral tablet 2.5 mg 1 or 1b* ST; DO levamlodipine maleate oral tablet 5 mg 1 or 1b* ST; QL matzim la oral tablet extended release 24 hour 1 or 1b* QL nicardipine hcl oral capsule 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 39