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 VASOTEC TABLET Y    
enalapril maleate ENALAPRIL MALEATE TABLET Y    
irbesartan IRBESARTAN TABLET Y    
irbesartan AVAPRO TABLET Y    
lisinopril ZESTRIL TABLET Y    
lisinopril PRINIVIL 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 RAMIPRIL CAPSULE Y    
ramipril ALTACE CAPSULE Y    
telmisartan TELMISARTAN TABLET Y    
telmisartan MICARDIS TABLET Y    
valsartan VALSARTAN TABLET Y    
valsartan DIOVAN TABLET Y    
aliskiren hemifumarate TEKTURNA TABLET N    
azilsartan medoxomil EDARBI TABLET N    
candesartan cilexetil CANDESARTAN CILEXETIL TABLET N    
candesartan cilexetil ATACAND TABLET N    
captopril CAPTOPRIL TABLET N    
enalapril maleate EPANED SOLN RECON 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 QUINAPRIL HCL TABLET N    
quinapril HCl ACCUPRIL TABLET N    
trandolapril TRANDOLAPRIL TABLET N    
sacubitril/valsartan ENTRESTO TABLET PA Document Sep 24, 2015