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 FUROSEMIDE TABLET Y    
FUROSEMIDE LASIX TABLET Y    
HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE CAPSULE Y    
HYDROCHLOROTHIAZIDE MICROZIDE CAPSULE Y    
HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE TABLET Y    
INDAPAMIDE INDAPAMIDE TABLET Y    
SPIRONOLACT/HYDROCHLOROTHIAZID ALDACTAZIDE TABLET Y    
SPIRONOLACT/HYDROCHLOROTHIAZID SPIRONOLACTONE-HCTZ TABLET Y    
SPIRONOLACTONE SPIRONOLACTONE TABLET Y    
SPIRONOLACTONE ALDACTONE TABLET Y    
TORSEMIDE DEMADEX TABLET Y    
TORSEMIDE TORSEMIDE TABLET Y    
TRIAMTERENE DYRENIUM CAPSULE Y    
TRIAMTERENE/HYDROCHLOROTHIAZID DYAZIDE CAPSULE Y    
TRIAMTERENE/HYDROCHLOROTHIAZID TRIAMTERENE-HYDROCHLOROTHIAZID 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 EDECRIN TABLET N    
ETHACRYNIC ACID ETHACRYNIC ACID TABLET N    
METHYCLOTHIAZIDE METHYCLOTHIAZIDE TABLET N    
METOLAZONE METOLAZONE TABLET N    
TRIAMTERENE/HYDROCHLOROTHIAZID MAXZIDE TABLET N    
TRIAMTERENE/HYDROCHLOROTHIAZID TRIAMTERENE-HYDROCHLOROTHIAZID TABLET N    
TRIAMTERENE/HYDROCHLOROTHIAZID MAXZIDE-25 MG TABLET N    
ACETAZOLAMIDE ACETAZOLAMIDE CAPSULE ER    
ACETAZOLAMIDE DIAMOX SEQUELS CAPSULE ER    
ACETAZOLAMIDE ACETAZOLAMIDE TABLET    
METHAZOLAMIDE METHAZOLAMIDE TABLET    
TOLVAPTAN SAMSCA TABLET