ACEIs, ARBs and DRIs

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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
BENAZEPRIL HCL LOTENSIN TABLET Y    
BENAZEPRIL HCL BENAZEPRIL HCL TABLET Y    
ENALAPRIL MALEATE ENALAPRIL MALEATE TABLET Y    
ENALAPRIL MALEATE VASOTEC TABLET Y    
IRBESARTAN AVAPRO TABLET Y    
IRBESARTAN IRBESARTAN TABLET Y    
LISINOPRIL PRINIVIL TABLET Y    
LISINOPRIL ZESTRIL TABLET Y    
LISINOPRIL LISINOPRIL TABLET Y    
LOSARTAN POTASSIUM LOSARTAN POTASSIUM TABLET Y    
LOSARTAN POTASSIUM COZAAR TABLET Y    
OLMESARTAN MEDOXOMIL BENICAR TABLET Y    
OLMESARTAN MEDOXOMIL OLMESARTAN MEDOXOMIL TABLET Y    
RAMIPRIL ALTACE CAPSULE Y    
RAMIPRIL RAMIPRIL CAPSULE Y    
TELMISARTAN MICARDIS TABLET Y    
TELMISARTAN TELMISARTAN TABLET Y    
VALSARTAN DIOVAN TABLET Y    
VALSARTAN VALSARTAN TABLET Y    
ALISKIREN HEMIFUMARATE TEKTURNA TABLET N    
AZILSARTAN MEDOXOMIL EDARBI TABLET N    
CANDESARTAN CILEXETIL ATACAND TABLET N    
CANDESARTAN CILEXETIL CANDESARTAN CILEXETIL TABLET N    
CAPTOPRIL CAPTOPRIL TABLET N    
EPROSARTAN MESYLATE EPROSARTAN MESYLATE TABLET N    
FOSINOPRIL SODIUM FOSINOPRIL SODIUM TABLET N    
LISINOPRIL QBRELIS SOLUTION N    
MOEXIPRIL HCL MOEXIPRIL HCL TABLET N    
PERINDOPRIL ERBUMINE PERINDOPRIL ERBUMINE TABLET N    
QUINAPRIL HCL ACCUPRIL TABLET N    
QUINAPRIL HCL QUINAPRIL HCL TABLET N    
TRANDOLAPRIL TRANDOLAPRIL TABLET N    
SACUBITRIL/VALSARTAN ENTRESTO TABLET PA Document Sep 24, 2015