Diuretics, Parenteral

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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
ACETAZOLAMIDE SODIUM ACETAZOLAMIDE SODIUM VIAL    
BUMETANIDE BUMETANIDE VIAL    
CHLOROTHIAZIDE SODIUM CHLOROTHIAZIDE SODIUM VIAL    
CONIVAPTAN HCL IN 5 % DEXTROSE VAPRISOL-5% DEXTROSE PLAST. BAG    
ETHACRYNATE SODIUM ETHACRYNATE SODIUM VIAL    
ETHACRYNATE SODIUM SODIUM EDECRIN VIAL    
FUROSEMIDE FUROSEMIDE SYRINGE    
FUROSEMIDE FUROSEMIDE VIAL    
MANNITOL RESECTISOL IRRIG SOLN    
MANNITOL MANNITOL IV SOLN    
MANNITOL OSMITROL IV SOLN    
MANNITOL MANNITOL VIAL