Diuretics, Other
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 |
|---|---|---|---|---|---|---|
| acetazolamide | ACETAZOLAMIDE ER | CAPSULE ER | N | |||
| acetazolamide | ACETAZOLAMIDE | TABLET | N | |||
| acetazolamide sodium | ACETAZOLAMIDE SODIUM | VIAL | N | |||
| bumetanide | BUMETANIDE | VIAL | N | |||
| chlorothiazide sodium | CHLOROTHIAZIDE SODIUM | VIAL | N | |||
| conivaptan HCl in 5 % dextrose | VAPRISOL-5% DEXTROSE | PLAST. BAG | N | |||
| ethacrynate sodium | ETHACRYNATE SODIUM | VIAL | N | |||
| furosemide | FUROSEMIDE | AMPUL | N | |||
| furosemide | FUROSCIX | KIT | N | |||
| furosemide | FUROSEMIDE | VIAL | N | |||
| isosorbide | ISMOTIC | SOLUTION | N | |||
| mannitol | MANNITOL | IV SOLN | N | |||
| mannitol | OSMITROL | IV SOLN | N | |||
| mannitol | MANNITOL | VIAL | N | |||
| methazolamide | METHAZOLAMIDE | TABLET | N | |||
| tolvaptan | TOLVAPTAN | TABLET | N | |||
| tolvaptan | JYNARQUE | TABLET | N | |||
| tolvaptan | SAMSCA | TABLET | N | |||
| tolvaptan | TOLVAPTAN | TABLET SEQ | N | |||
| tolvaptan | JYNARQUE | TABLET SEQ | N |