Drug Name Tier Notes nifedipine er oral tablet extended release 24 hour 2 QL nifedipine er osmotic release oral tablet extended release 24 hour 30 mg 2 DO nifedipine er osmotic release oral tablet extended release 24 hour 60 mg, 90 mg 2 QL nifedipine oral capsule 10 mg 2 DO nifedipine oral capsule 20 mg 2 QL nimodipine oral capsule 2 QL nimodipine oral solution 2 QL nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg, 8.5 mg 1 or 1b* DO nisoldipine er oral tablet extended release 24 hour 25.5 mg, 30 mg, 34 mg, 40 mg 1 or 1b* QL tiadylt er oral capsule extended release 24 hour 120 mg 1 or 1b* DO tiadylt er oral capsule extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg 1 or 1b* QL verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg 1 or 1b* DO verapamil hcl er oral capsule extended release 24 hour 200 mg, 240 mg, 300 mg, 360 mg 1 or 1b* QL verapamil hcl er oral tablet extended release 120 mg 1 or 1b* DO verapamil hcl er oral tablet extended release 180 mg, 240 mg 1 or 1b* QL verapamil hcl intravenous solution 1 or 1b* verapamil hcl oral tablet 120 mg 1 or 1b* QL verapamil hcl oral tablet 40 mg, 80 mg 1 or 1b* DO *CARDIOTONICS* *CARDIAC GLYCOSIDES*** digoxin injection solution 1 or 1b* digoxin oral solution 1 or 1b* QL digoxin oral tablet 125 mcg, 62.5 mcg 1 or 1b* DO Drug Name Tier Notes digoxin oral tablet 250 mcg 1 or 1b* QL LANOXIN PEDIATRIC INJECTION SOLUTION 2 *INOTROPES*** dobutamine hcl intravenous solution 12.5 mg/ml, 250 mg/20ml 1 or 1b* milrinone lactate in dextrose intravenous solution 1 or 1b* milrinone lactate intravenous solution 10 mg/10ml, 20 mg/20ml, 50 mg/50ml 1 or 1b* *CARDIOVASCULAR AGENTS - MISC.* *CALCIUM CHANNEL BLOCKER & HMG COA REDUCTASE INHIBIT COMB*** amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 5-80 mg 1 or 1b* QL amlodipine-atorvastatin oral tablet 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg 1 or 1b* DO *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** ENTRESTO ORAL CAPSULE SPRINKLE 3 QL ENTRESTO ORAL TABLET 3 QL *NITRATE & VASODILATOR COMBINATIONS*** isosorb dinitrate-hydralazine oral tablet 20-37.5 mg 2 QL *PROSTAGLANDIN VASODILATORS*** alprostadil injection solution 1 or 1b* ORENITRAM ORAL TABLET EXTENDED RELEASE 4 PA; LD; SP treprostinil injection solution 4 PA; LD; SP VENTAVIS INHALATION SOLUTION 4 PA; LD; QL; SP * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 40