Diuretics, Oral

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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
amiloride HCl AMILORIDE HCL TABLET Y    
amiloride/hydrochlorothiazide AMILORIDE-HYDROCHLOROTHIAZIDE TABLET Y    
bumetanide BUMETANIDE TABLET Y    
furosemide FUROSEMIDE SOLUTION Y 40 mg/5 mL (8 mg/mL), 40 mg/4 mL Require PA  
furosemide LASIX TABLET Y    
furosemide FUROSEMIDE TABLET Y    
hydrochlorothiazide HYDROCHLOROTHIAZIDE CAPSULE Y    
hydrochlorothiazide MICROZIDE CAPSULE Y    
hydrochlorothiazide HYDROCHLOROTHIAZIDE TABLET Y    
indapamide INDAPAMIDE TABLET Y    
spironolact/hydrochlorothiazid SPIRONOLACTONE-HCTZ TABLET Y    
spironolact/hydrochlorothiazid ALDACTAZIDE TABLET Y    
spironolactone SPIRONOLACTONE TABLET Y    
spironolactone ALDACTONE TABLET Y    
torsemide TORSEMIDE TABLET Y    
triamterene DYRENIUM CAPSULE Y    
triamterene/hydrochlorothiazid TRIAMTERENE-HYDROCHLOROTHIAZID CAPSULE Y    
triamterene/hydrochlorothiazid DYAZIDE CAPSULE Y    
chlorothiazide DIURIL ORAL SUSP N    
chlorothiazide CHLOROTHIAZIDE TABLET N    
chlorthalidone CHLORTHALIDONE TABLET N    
eplerenone INSPRA TABLET N    
eplerenone EPLERENONE TABLET N    
ethacrynic acid ETHACRYNIC ACID TABLET N    
ethacrynic acid EDECRIN TABLET N    
methyclothiazide METHYCLOTHIAZIDE TABLET N    
metolazone METOLAZONE TABLET N    
spironolactone CAROSPIR ORAL SUSP N    
triamterene/hydrochlorothiazid MAXZIDE-25 MG TABLET N    
triamterene/hydrochlorothiazid TRIAMTERENE-HYDROCHLOROTHIAZID TABLET N    
triamterene/hydrochlorothiazid MAXZIDE TABLET N    
acetazolamide ACETAZOLAMIDE CAPSULE ER    
acetazolamide DIAMOX SEQUELS CAPSULE ER    
acetazolamide ACETAZOLAMIDE TABLET    
methazolamide METHAZOLAMIDE TABLET    
tolvaptan SAMSCA TABLET