Combination Antihypertensives
PDL Reference Documents
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.
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 | AMLODIPINE-OLMESARTAN | TABLET | Y | ||
| amlodipine bes/olmesartan med | AZOR | TABLET | Y | ||
| benazepril/hydrochlorothiazide | LOTENSIN HCT | TABLET | Y | ||
| benazepril/hydrochlorothiazide | BENAZEPRIL-HYDROCHLOROTHIAZIDE | TABLET | Y | ||
| enalapril/hydrochlorothiazide | ENALAPRIL MALEATE/HCTZ | TABLET | Y | ||
| enalapril/hydrochlorothiazide | ENALAPRIL-HYDROCHLOROTHIAZIDE | TABLET | Y | ||
| enalapril/hydrochlorothiazide | VASERETIC | TABLET | Y | ||
| lisinopril/hydrochlorothiazide | ZESTORETIC | TABLET | Y | ||
| lisinopril/hydrochlorothiazide | LISINOPRIL-HYDROCHLOROTHIAZIDE | TABLET | Y | ||
| losartan/hydrochlorothiazide | LOSARTAN-HYDROCHLOROTHIAZIDE | TABLET | Y | ||
| losartan/hydrochlorothiazide | HYZAAR | TABLET | Y | ||
| olmesartan/amlodipin/hcthiazid | OLMESARTAN-AMLODIPINE-HCTZ | TABLET | Y | ||
| olmesartan/amlodipin/hcthiazid | TRIBENZOR | 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 | AMLODIPINE BESYLATE-BENAZEPRIL | CAPSULE | N | ||
| amlodipine besylate/benazepril | LOTREL | CAPSULE | N | ||
| amlodipine besylate/valsartan | AMLODIPINE-VALSARTAN | TABLET | N | ||
| amlodipine besylate/valsartan | EXFORGE | TABLET | N | ||
| amlodipine/atorvastatin | CADUET | TABLET | N | ||
| amlodipine/atorvastatin | AMLODIPINE-ATORVASTATIN | TABLET | N | ||
| amlodipine/valsartan/hcthiazid | AMLODIPINE-VALSARTAN-HCTZ | TABLET | N | ||
| atenolol/chlorthalidone | ATENOLOL W/CHLORTHALIDONE | TABLET | N | ||
| atenolol/chlorthalidone | ATENOLOL-CHLORTHALIDONE | TABLET | N | ||
| atenolol/chlorthalidone | TENORETIC 50 | TABLET | N | ||
| atenolol/chlorthalidone | TENORETIC 100 | TABLET | N | ||
| azilsartan med/chlorthalidone | EDARBYCLOR | TABLET | N | ||
| bisoprolol/hydrochlorothiazide | BISOPROLOL FUMARATE/HCTZ | 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 | ||
| 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 | ||
| propranolol/hydrochlorothiazid | PROPRANOLOL HCL W/HCTZ | TABLET | N | ||
| quinapril/hydrochlorothiazide | ACCURETIC | TABLET | N | ||
| quinapril/hydrochlorothiazide | QUINAPRIL-HYDROCHLOROTHIAZIDE | TABLET | N | ||
| telmisartan/amlodipine | TELMISARTAN-AMLODIPINE | TABLET | N | ||
| trandolapril/verapamil HCl | TRANDOLAPRIL-VERAPAMIL ER | TAB BP 24H | N | ||
| valsartan/hydrochlorothiazide | DIOVAN HCT | TABLET | N | ||
| valsartan/hydrochlorothiazide | VALSARTAN-HYDROCHLOROTHIAZIDE | TABLET | N | ||
| bisoprolol/hydrochlorothiazide | BISOPROLOL-HYDROCHLOROTHIAZIDE | TABLET |