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.
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 |
|---|---|---|---|---|---|---|
| amiloride/hydrochlorothiazide | AMILORIDE HCL W/HCTZ | TABLET | Y | N | ||
| bumetanide | BUMETANIDE | TABLET | Y | N | ||
| furosemide | FUROSEMIDE | TABLET | Y | N | ||
| hydrochlorothiazide | HYDROCHLOROTHIAZIDE | TABLET | Y | N | ||
| spironolact/hydrochlorothiazid | SPIRONOLACTONE-HCTZ | TABLET | Y | N | ||
| spironolactone | SPIRONOLACTONE | TABLET | Y | N | ||
| spironolactone | ALDACTONE | TABLET | Y | N | ||
| triamterene | TRIAMTERENE | CAPSULE | Y | N | ||
| triamterene/hydrochlorothiazid | TRIAMTERENE W/HCTZ | TABLET | Y | N | ||
| chlorthalidone | HEMICLOR | TABLET | N | N | ||
| chlorthalidone | THALITONE | TABLET | N | N | ||
| eplerenone | EPLERENONE | TABLET | N | N | ||
| ethacrynic acid | ETHACRYNIC ACID | TABLET | N | N | ||
| furosemide | FUROSEMIDE | SOLUTION | N | N | ||
| spironolactone | CAROSPIR | ORAL SUSP | N | N | ||
| hydroflumethiazide | SALURON | TABLET | N |