Combination Antihypertensives

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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
amlodipine bes/olmesartan med AZOR TABLET Y    
amlodipine bes/olmesartan med AMLODIPINE-OLMESARTAN TABLET Y    
benazepril/hydrochlorothiazide LOTENSIN HCT TABLET Y    
benazepril/hydrochlorothiazide BENAZEPRIL-HYDROCHLOROTHIAZIDE TABLET Y    
enalapril/hydrochlorothiazide VASERETIC TABLET Y    
enalapril/hydrochlorothiazide ENALAPRIL-HYDROCHLOROTHIAZIDE TABLET Y    
lisinopril/hydrochlorothiazide LISINOPRIL-HCTZ TABLET Y    
lisinopril/hydrochlorothiazide ZESTORETIC TABLET Y    
lisinopril/hydrochlorothiazide LISINOPRIL-HYDROCHLOROTHIAZIDE TABLET Y    
losartan/hydrochlorothiazide LOSARTAN-HYDROCHLOROTHIAZIDE TABLET Y    
losartan/hydrochlorothiazide HYZAAR TABLET Y    
metoprolol su/hydrochlorothiaz DUTOPROL TAB ER 24H Y    
olmesartan/amlodipin/hcthiazid TRIBENZOR TABLET Y    
olmesartan/amlodipin/hcthiazid OLMESARTAN-AMLODIPINE-HCTZ TABLET Y    
olmesartan/hydrochlorothiazide BENICAR HCT TABLET Y    
olmesartan/hydrochlorothiazide OLMESARTAN-HYDROCHLOROTHIAZIDE TABLET Y    
telmisartan/hydrochlorothiazid TELMISARTAN-HYDROCHLOROTHIAZID TABLET Y    
telmisartan/hydrochlorothiazid MICARDIS HCT TABLET Y    
aliskiren/hydrochlorothiazide TEKTURNA HCT TABLET N    
amlodipine besylate/benazepril LOTREL CAPSULE N    
amlodipine besylate/benazepril AMLODIPINE BESYLATE-BENAZEPRIL CAPSULE N    
amlodipine besylate/valsartan EXFORGE TABLET N    
amlodipine besylate/valsartan AMLODIPINE-VALSARTAN TABLET N    
amlodipine/atorvastatin CADUET TABLET N    
amlodipine/atorvastatin AMLODIPINE-ATORVASTATIN TABLET N    
amlodipine/valsartan/hcthiazid EXFORGE HCT TABLET N    
amlodipine/valsartan/hcthiazid AMLODIPINE-VALSARTAN-HCTZ TABLET N    
atenolol/chlorthalidone ATENOLOL-CHLORTHALIDONE TABLET N    
atenolol/chlorthalidone TENORETIC 100 TABLET N    
atenolol/chlorthalidone TENORETIC 50 TABLET N    
azilsartan med/chlorthalidone EDARBYCLOR TABLET N    
bisoprolol/hydrochlorothiazide ZIAC TABLET N    
bisoprolol/hydrochlorothiazide BISOPROLOL-HYDROCHLOROTHIAZIDE TABLET N    
candesartan/hydrochlorothiazid CANDESARTAN-HYDROCHLOROTHIAZID TABLET N    
candesartan/hydrochlorothiazid ATACAND HCT TABLET N    
captopril/hydrochlorothiazide CAPTOPRIL-HYDROCHLOROTHIAZIDE TABLET N    
fosinopril/hydrochlorothiazide FOSINOPRIL-HYDROCHLOROTHIAZIDE TABLET N    
irbesartan/hydrochlorothiazide AVALIDE TABLET N    
irbesartan/hydrochlorothiazide IRBESARTAN-HYDROCHLOROTHIAZIDE TABLET N    
metoprolol/hydrochlorothiazide METOPROLOL-HYDROCHLOROTHIAZIDE TABLET N    
moexipril/hydrochlorothiazide MOEXIPRIL-HYDROCHLOROTHIAZIDE TABLET N    
nadolol/bendroflumethiazide NADOLOL-BENDROFLUMETHIAZIDE TABLET N    
nadolol/bendroflumethiazide CORZIDE TABLET N    
perindopril arg/amlodipine bes PRESTALIA TABLET N    
propranolol/hydrochlorothiazid PROPRANOLOL-HYDROCHLOROTHIAZID TABLET N    
quinapril/hydrochlorothiazide ACCURETIC TABLET N    
quinapril/hydrochlorothiazide QUINAPRIL-HYDROCHLOROTHIAZIDE TABLET N    
telmisartan/amlodipine TWYNSTA TABLET N    
telmisartan/amlodipine TELMISARTAN-AMLODIPINE TABLET N    
trandolapril/verapamil HCl TRANDOLAPRIL-VERAPAMIL ER TAB BP 24H N    
trandolapril/verapamil HCl TARKA TAB BP 24H N    
valsartan/hydrochlorothiazide VALSARTAN-HYDROCHLOROTHIAZIDE TABLET N    
valsartan/hydrochlorothiazide DIOVAN HCT TABLET N