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 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    
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 MICARDIS HCT TABLET Y    
TELMISARTAN/HYDROCHLOROTHIAZID TELMISARTAN-HYDROCHLOROTHIAZID 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 AMLODIPINE-VALSARTAN TABLET N    
AMLODIPINE BESYLATE/VALSARTAN EXFORGE 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 TELMISARTAN-AMLODIPINE TABLET N    
TELMISARTAN/AMLODIPINE TWYNSTA TABLET N    
TRANDOLAPRIL/VERAPAMIL HCL TRANDOLAPRIL-VERAPAMIL ER TAB BP 24H N    
TRANDOLAPRIL/VERAPAMIL HCL TARKA TAB BP 24H N    
VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCT TABLET N    
VALSARTAN/HYDROCHLOROTHIAZIDE VALSARTAN-HYDROCHLOROTHIAZIDE TABLET N