Combination Antihypertensives
PDL Reference Documents
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 |
|---|---|---|---|---|---|---|
| amlodipine bes/olmesartan med | AZOR | TABLET | Y | N | ||
| benazepril/hydrochlorothiazide | LOTENSIN HCT | TABLET | Y | N | ||
| enalapril/hydrochlorothiazide | ENALAPRIL MALEATE/HCTZ | TABLET | Y | N | ||
| lisinopril/hydrochlorothiazide | LISINOPRIL-HYDROCHLOROTHIAZIDE | TABLET | Y | N | ||
| losartan/hydrochlorothiazide | HYZAAR | TABLET | Y | N | ||
| olmesartan/amlodipin/hcthiazid | OLMESARTAN-AMLODIPINE-HCTZ | TABLET | Y | N | ||
| olmesartan/amlodipin/hcthiazid | TRIBENZOR | TABLET | Y | N | ||
| olmesartan/hydrochlorothiazide | OLMESARTAN-HYDROCHLOROTHIAZIDE | TABLET | Y | N | ||
| amlodipine besylate/benazepril | AMLODIPINE BESYLATE-BENAZEPRIL | CAPSULE | N | N | ||
| amlodipine besylate/valsartan | AMLODIPINE-VALSARTAN | TABLET | N | N | ||
| amlodipine/atorvastatin | CADUET | TABLET | N | N | ||
| amlodipine/atorvastatin | AMLODIPINE-ATORVASTATIN | TABLET | N | N | ||
| amlodipine/valsartan/hcthiazid | AMLODIPINE-VALSARTAN-HCTZ | TABLET | N | N | ||
| atenolol/chlorthalidone | ATENOLOL-CHLORTHALIDONE | TABLET | N | N | ||
| atenolol/chlorthalidone | TENORETIC 100 | TABLET | N | N | ||
| azilsartan med/chlorthalidone | EDARBYCLOR | TABLET | N | N | ||
| candesartan/hydrochlorothiazid | CANDESARTAN-HYDROCHLOROTHIAZID | TABLET | N | N | ||
| irbesartan/hydrochlorothiazide | AVALIDE | TABLET | N | N | ||
| metoprolol/hydrochlorothiazide | METOPROLOL-HYDROCHLOROTHIAZIDE | TABLET | N | N | ||
| quinapril/hydrochlorothiazide | ACCURETIC | TABLET | N | N | ||
| telmisartan/amlodipine | TELMISARTAN-AMLODIPINE | TABLET | N | N | ||
| trandolapril/verapamil HCl | TRANDOLAPRIL-VERAPAMIL ER | TAB BP 24H | N | N | ||
| valsartan/hydrochlorothiazide | VALSARTAN-HYDROCHLOROTHIAZIDE | TABLET | N | N |