Diuretics, Other

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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.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
16729033101 ACETAZOLAMIDE ER acetazolamide CAPSULE ER 500 mg Y N  
23155012001 ACETAZOLAMIDE ER acetazolamide CAPSULE ER 500 mg Y N  
23155078701 ACETAZOLAMIDE ER acetazolamide CAPSULE ER 500 mg Y N  
42571024301 ACETAZOLAMIDE ER acetazolamide CAPSULE ER 500 mg Y N  
50268004211 ACETAZOLAMIDE ER acetazolamide CAPSULE ER 500 mg Y N  
50268004212 ACETAZOLAMIDE ER acetazolamide CAPSULE ER 500 mg Y N  
60687057811 ACETAZOLAMIDE ER acetazolamide CAPSULE ER 500 mg Y N  
60687057821 ACETAZOLAMIDE ER acetazolamide CAPSULE ER 500 mg Y N  
62135061260 ACETAZOLAMIDE ER acetazolamide CAPSULE ER 500 mg Y N  
69367020901 ACETAZOLAMIDE ER acetazolamide CAPSULE ER 500 mg Y N  
70710159101 ACETAZOLAMIDE ER acetazolamide CAPSULE ER 500 mg Y N  
23155028701 ACETAZOLAMIDE acetazolamide TABLET 125 mg Y N  
51672402201 ACETAZOLAMIDE acetazolamide TABLET 125 mg Y N  
52817020010 ACETAZOLAMIDE acetazolamide TABLET 125 mg Y N  
59651090501 ACETAZOLAMIDE acetazolamide TABLET 125 mg Y N  
62135060712 ACETAZOLAMIDE acetazolamide TABLET 125 mg Y N  
64380083306 ACETAZOLAMIDE acetazolamide TABLET 125 mg Y N  
70756072011 ACETAZOLAMIDE acetazolamide TABLET 125 mg Y N  
70954003330 ACETAZOLAMIDE acetazolamide TABLET 125 mg Y N  
71930000812 ACETAZOLAMIDE acetazolamide TABLET 125 mg Y N  
72578014901 ACETAZOLAMIDE acetazolamide TABLET 125 mg Y N  
72888004701 ACETAZOLAMIDE acetazolamide TABLET 125 mg Y N  
00904666361 ACETAZOLAMIDE acetazolamide TABLET 250 mg Y N  
23155028801 ACETAZOLAMIDE acetazolamide TABLET 250 mg Y N  
50268005411 ACETAZOLAMIDE acetazolamide TABLET 250 mg Y N  
50268005415 ACETAZOLAMIDE acetazolamide TABLET 250 mg Y N  
51672402301 ACETAZOLAMIDE acetazolamide TABLET 250 mg Y N  
52817020110 ACETAZOLAMIDE acetazolamide TABLET 250 mg Y N  
59651090601 ACETAZOLAMIDE acetazolamide TABLET 250 mg Y N  
62135060812 ACETAZOLAMIDE acetazolamide TABLET 250 mg Y N  
63739025701 ACETAZOLAMIDE acetazolamide TABLET 250 mg Y N  
64380083406 ACETAZOLAMIDE acetazolamide TABLET 250 mg Y N  
70756072111 ACETAZOLAMIDE acetazolamide TABLET 250 mg Y N  
70954003430 ACETAZOLAMIDE acetazolamide TABLET 250 mg Y N  
71930000912 ACETAZOLAMIDE acetazolamide TABLET 250 mg Y N  
72578015001 ACETAZOLAMIDE acetazolamide TABLET 250 mg Y N  
72888004801 ACETAZOLAMIDE acetazolamide TABLET 250 mg Y N  
00143900601 ACETAZOLAMIDE SODIUM acetazolamide sodium VIAL 500 mg Y N  
00143950301 ACETAZOLAMIDE SODIUM acetazolamide sodium VIAL 500 mg Y N  
23155031331 ACETAZOLAMIDE SODIUM acetazolamide sodium VIAL 500 mg Y N  
23155083131 ACETAZOLAMIDE SODIUM acetazolamide sodium VIAL 500 mg Y N  
39822019001 ACETAZOLAMIDE SODIUM acetazolamide sodium VIAL 500 mg Y N  
67457085350 ACETAZOLAMIDE SODIUM acetazolamide sodium VIAL 500 mg Y N  
00641600701 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
00641600710 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
00641600801 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
00641600810 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
00641628401 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
00641628410 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
00641628501 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
00641628510 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
25021032104 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
25021032110 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
31722036831 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
31722036832 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
31722036910 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
31722036932 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
65219057001 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
65219057004 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
65219057201 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
65219057210 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
68462046940 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
68462046954 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
68462047040 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
68462047054 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
70748032301 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
70748032302 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
70748032310 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
70748032311 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
70860040504 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
70860040541 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
70860040610 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
70860040641 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
72205010101 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
72205010107 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
72205010201 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
72205010207 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
72572004001 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
72572004010 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
72572004101 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
72572004110 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
83301008001 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
83301008002 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
83301008101 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
83301008102 BUMETANIDE bumetanide VIAL 0.25 mg/mL Y N  
00517182001 CHLOROTHIAZIDE SODIUM chlorothiazide sodium VIAL 500 mg Y N  
25021030520 CHLOROTHIAZIDE SODIUM chlorothiazide sodium VIAL 500 mg Y N  
25021030566 CHLOROTHIAZIDE SODIUM chlorothiazide sodium VIAL 500 mg Y N  
47335033040 CHLOROTHIAZIDE SODIUM chlorothiazide sodium VIAL 500 mg Y N  
63323065820 CHLOROTHIAZIDE SODIUM chlorothiazide sodium VIAL 500 mg Y N  
63323065827 CHLOROTHIAZIDE SODIUM chlorothiazide sodium VIAL 500 mg Y N  
63323065894 CHLOROTHIAZIDE SODIUM chlorothiazide sodium VIAL 500 mg Y N  
66220016010 VAPRISOL-5% DEXTROSE conivaptan HCl in 5 % dextrose PLAST. BAG 20 mg/100 mL Y N  
42023015701 ETHACRYNATE SODIUM ethacrynate sodium VIAL 50 mg Y N  
69315070150 ETHACRYNATE SODIUM ethacrynate sodium VIAL 50 mg Y N  
10019001076 FUROSEMIDE furosemide AMPUL 10 mg/mL Y N  
71767010001 FUROSCIX furosemide KIT 80 mg/10 mL Y N  
00143915501 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
00143915525 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
00143915601 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
00143915610 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
00143915701 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
00143915710 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
00143915801 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
00143915901 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
00409610202 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
00409610204 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
00409610210 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
00409610218 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
00409610219 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
00409610220 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
00409610225 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
00409610226 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
00409610227 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
00409610235 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
00409610236 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
00409610237 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
16729050008 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
16729050030 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
16729050143 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
16729050164 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
16729050203 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
16729050243 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
23155047331 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
23155047332 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
23155047333 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
23155047341 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
23155047342 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
23155047344 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
25021031102 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
25021031104 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
25021031110 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
25021032002 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
25021032004 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
25021032010 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
36000028225 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
36000028325 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
36000028425 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
55150032201 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
55150032225 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
55150032301 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
55150032325 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
55150032401 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
55150032425 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
63323028001 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
63323028002 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
63323028003 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
63323028004 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
63323028005 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
63323028010 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
63323028016 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
63323028026 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
63323028036 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
63323028041 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
63323028043 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
63323028045 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
70121107601 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
70121107605 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
71288020302 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
71288020303 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
71288020304 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
71288020305 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
71288020310 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
71288020311 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
72572019001 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
72572019025 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
72603013301 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
72603013325 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
72603025101 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
72603025125 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
72603047401 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
72603047425 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
73043002201 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
73043002291 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
73043002301 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
73043002391 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
73043002401 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
73043002491 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
81565020101 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
81565020102 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
83634030202 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
83634030204 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
83634030210 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
83634030241 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
83634030242 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
83634030243 FUROSEMIDE furosemide VIAL 10 mg/mL Y N  
00065003408 ISMOTIC isosorbide SOLUTION 45 % Y N  
00338034503 OSMITROL mannitol IV SOLN 10 % (100 mg/mL) Y N  
00338034504 OSMITROL mannitol IV SOLN 10 % (100 mg/mL) Y N  
00338035303 OSMITROL mannitol IV SOLN 10 % (100 mg/mL) Y N  
00338034701 OSMITROL mannitol IV SOLN 15 % (150 mg/mL) Y N  
00338034703 OSMITROL mannitol IV SOLN 15 % (150 mg/mL) Y N  
00264757810 MANNITOL mannitol IV SOLN 20 % (200 mg/mL) Y N  
00990771502 MANNITOL mannitol IV SOLN 20 % (200 mg/mL) Y N  
00990771503 MANNITOL mannitol IV SOLN 20 % (200 mg/mL) Y N  
00990771512 MANNITOL mannitol IV SOLN 20 % (200 mg/mL) Y N  
00990771513 MANNITOL mannitol IV SOLN 20 % (200 mg/mL) Y N  
00338034902 OSMITROL mannitol IV SOLN 20 % (200 mg/mL) Y N  
00338034903 OSMITROL mannitol IV SOLN 20 % (200 mg/mL) Y N  
00338035702 OSMITROL mannitol IV SOLN 20 % (200 mg/mL) Y N  
00338035703 OSMITROL mannitol IV SOLN 20 % (200 mg/mL) Y N  
00338034304 OSMITROL mannitol IV SOLN 5 % (50 mg/mL) Y N  
00409403101 MANNITOL mannitol VIAL 25 % (250 mg/mL) Y N  
00409403116 MANNITOL mannitol VIAL 25 % (250 mg/mL) Y N  
63323002401 MANNITOL mannitol VIAL 25 % (250 mg/mL) Y N  
63323002425 MANNITOL mannitol VIAL 25 % (250 mg/mL) Y N  
00574079001 METHAZOLAMIDE methazolamide TABLET 25 mg Y N  
00904778160 METHAZOLAMIDE methazolamide TABLET 25 mg Y N  
24208002210 METHAZOLAMIDE methazolamide TABLET 25 mg Y N  
62559024001 METHAZOLAMIDE methazolamide TABLET 25 mg Y N  
68094090850 METHAZOLAMIDE methazolamide TABLET 25 mg Y N  
72603016601 METHAZOLAMIDE methazolamide TABLET 25 mg Y N  
00574079101 METHAZOLAMIDE methazolamide TABLET 50 mg Y N  
00904778260 METHAZOLAMIDE methazolamide TABLET 50 mg Y N  
24208002310 METHAZOLAMIDE methazolamide TABLET 50 mg Y N  
62559024101 METHAZOLAMIDE methazolamide TABLET 50 mg Y N  
68094080850 METHAZOLAMIDE methazolamide TABLET 50 mg Y N  
72603016701 METHAZOLAMIDE methazolamide TABLET 50 mg Y N  
59148008213 JYNARQUE tolvaptan TABLET 15 mg Y N  
59148002050 SAMSCA tolvaptan TABLET 15 mg Y N  
31722086803 TOLVAPTAN tolvaptan TABLET 15 mg Y N  
31722086831 TOLVAPTAN tolvaptan TABLET 15 mg Y N  
49884076852 TOLVAPTAN tolvaptan TABLET 15 mg Y N  
49884076854 TOLVAPTAN tolvaptan TABLET 15 mg Y N  
60505431700 TOLVAPTAN tolvaptan TABLET 15 mg Y N  
60505470402 TOLVAPTAN tolvaptan TABLET 15 mg Y N  
67877063502 TOLVAPTAN tolvaptan TABLET 15 mg Y N  
67877063533 TOLVAPTAN tolvaptan TABLET 15 mg Y N  
70748023806 TOLVAPTAN tolvaptan TABLET 15 mg Y N  
72205013011 TOLVAPTAN tolvaptan TABLET 15 mg Y N  
59148008313 JYNARQUE tolvaptan TABLET 30 mg Y N  
59148002150 SAMSCA tolvaptan TABLET 30 mg Y N  
31722086901 TOLVAPTAN tolvaptan TABLET 30 mg Y N  
31722086903 TOLVAPTAN tolvaptan TABLET 30 mg Y N  
31722086931 TOLVAPTAN tolvaptan TABLET 30 mg Y N  
49884077052 TOLVAPTAN tolvaptan TABLET 30 mg Y N  
49884077054 TOLVAPTAN tolvaptan TABLET 30 mg Y N  
60505431800 TOLVAPTAN tolvaptan TABLET 30 mg Y N  
60505470501 TOLVAPTAN tolvaptan TABLET 30 mg Y N  
67877063602 TOLVAPTAN tolvaptan TABLET 30 mg Y N  
67877063633 TOLVAPTAN tolvaptan TABLET 30 mg Y N  
70748023906 TOLVAPTAN tolvaptan TABLET 30 mg Y N  
72205013111 TOLVAPTAN tolvaptan TABLET 30 mg Y N  
59148007907 JYNARQUE tolvaptan TABLET SEQ 15 mg (AM)/15 mg (PM) Y N  
59148007928 JYNARQUE tolvaptan TABLET SEQ 15 mg (AM)/15 mg (PM) Y N  
70748024011 TOLVAPTAN tolvaptan TABLET SEQ 15 mg (AM)/15 mg (PM) Y N  
70748024013 TOLVAPTAN tolvaptan TABLET SEQ 15 mg (AM)/15 mg (PM) Y N  
59148008007 JYNARQUE tolvaptan TABLET SEQ 30 mg (AM)/15 mg (PM) Y N  
59148008028 JYNARQUE tolvaptan TABLET SEQ 30 mg (AM)/15 mg (PM) Y N  
70748024111 TOLVAPTAN tolvaptan TABLET SEQ 30 mg (AM)/15 mg (PM) Y N  
70748024113 TOLVAPTAN tolvaptan TABLET SEQ 30 mg (AM)/15 mg (PM) Y N  
59148008707 JYNARQUE tolvaptan TABLET SEQ 45 mg (AM)/15 mg (PM) Y N  
59148008728 JYNARQUE tolvaptan TABLET SEQ 45 mg (AM)/15 mg (PM) Y N  
70748024211 TOLVAPTAN tolvaptan TABLET SEQ 45 mg (AM)/15 mg (PM) Y N  
70748024213 TOLVAPTAN tolvaptan TABLET SEQ 45 mg (AM)/15 mg (PM) Y N  
59148008807 JYNARQUE tolvaptan TABLET SEQ 60 mg (AM)/30 mg (PM) Y N  
59148008828 JYNARQUE tolvaptan TABLET SEQ 60 mg (AM)/30 mg (PM) Y N  
70748024311 TOLVAPTAN tolvaptan TABLET SEQ 60 mg (AM)/30 mg (PM) Y N  
70748024313 TOLVAPTAN tolvaptan TABLET SEQ 60 mg (AM)/30 mg (PM) Y N  
59148008907 JYNARQUE tolvaptan TABLET SEQ 90 mg (AM)/30 mg (PM) Y N  
59148008928 JYNARQUE tolvaptan TABLET SEQ 90 mg (AM)/30 mg (PM) Y N  
70748024411 TOLVAPTAN tolvaptan TABLET SEQ 90 mg (AM)/30 mg (PM) Y N  
70748024413 TOLVAPTAN tolvaptan TABLET SEQ 90 mg (AM)/30 mg (PM) Y N  
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