Inhibitors of the Renin-Angiotensin-Aldosterone System (RAAS)
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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.
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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| benazepril HCl | LOTENSIN | TABLET | Y | N | ||
| candesartan cilexetil | CANDESARTAN CILEXETIL | TABLET | Y | N | ||
| fosinopril sodium | FOSINOPRIL SODIUM | TABLET | Y | N | ||
| irbesartan | IRBESARTAN | TABLET | Y | N | ||
| lisinopril | LISINOPRIL | TABLET | Y | N | ||
| losartan potassium | LOSARTAN POTASSIUM | TABLET | Y | N | ||
| losartan potassium | COZAAR | TABLET | Y | N | ||
| olmesartan medoxomil | BENICAR | TABLET | Y | N | ||
| ramipril | RAMIPRIL | CAPSULE | Y | N | ||
| valsartan | VALSARTAN | TABLET | Y | N | ||
| aliskiren hemifumarate | ALISKIREN | TABLET | N | N | ||
| aliskiren hemifumarate | TEKTURNA | TABLET | N | N | ||
| enalapril maleate | EPANED | SOLUTION | N | N | ||
| perindopril erbumine | PERINDOPRIL ERBUMINE | TABLET | N | N | ||
| sacubitril/valsartan | ENTRESTO SPRINKLE | PEL DSP CP | N | Pharmacy PA | N | |
| sacubitril/valsartan | SACUBITRIL-VALSARTAN | TABLET | N | Pharmacy PA | N | |
| trandolapril | TRANDOLAPRIL | TABLET | N | N | ||
| valsartan | VALSARTAN | SOLUTION | N |