Drug Name Tier Notes captopril- hydrochlorothiazide oral tablet 1 or 1b* QL enalapril-hydrochlorothiazide oral tablet 1 or 1b* QL fosinopril sodium-hctz oral tablet 1 or 1b* QL lisinopril- hydrochlorothiazide oral tablet 1 or 1b* QL quinapril- hydrochlorothiazide oral tablet 1 or 1b* QL *ACE INHIBITORS*** benazepril hcl oral tablet 1 or 1a* QL captopril oral tablet 1 or 1b* QL enalapril maleate oral solution 2 QL enalapril maleate oral tablet 1 or 1b* QL enalaprilat intravenous solution 1 or 1b* fosinopril sodium oral tablet 1 or 1b* QL lisinopril oral tablet 1 or 1a* QL moexipril hcl oral tablet 1 or 1b* QL perindopril erbumine oral tablet 1 or 1b* QL quinapril hcl oral tablet 1 or 1b* QL ramipril oral capsule 1 or 1b* QL trandolapril oral tablet 1 or 1b* QL *AGENTS FOR PHEOCHROMOCYTOM A*** metyrosine oral capsule 1 or 1b* PA; LD; QL; SP phenoxybenzamine hcl oral capsule 2 PA; QL phentolamine mesylate injection solution reconstituted 1 or 1b* *ANGIOTENSIN II RECEPTOR ANTAG & CA CHANNEL BLOCKER COMB*** amlodipine besylate- valsartan oral tablet 1 or 1b* QL amlodipine-olmesartan oral tablet 1 or 1b* QL telmisartan-amlodipine oral tablet 1 or 1b* QL Drug Name Tier Notes *ANGIOTENSIN II RECEPTOR ANTAG & THIAZIDE/THIAZIDE- LIKE*** candesartan cilexetil-hctz oral tablet 1 or 1b* QL irbesartan- hydrochlorothiazide oral tablet 1 or 1b* QL losartan potassium-hctz oral tablet 1 or 1b* QL olmesartan medoxomil-hctz oral tablet 1 or 1b* QL telmisartan-hctz oral tablet 1 or 1b* QL valsartan- hydrochlorothiazide oral tablet 1 or 1b* QL *ANGIOTENSIN II RECEPTOR ANTAGONISTS*** candesartan cilexetil oral tablet 16 mg, 32 mg 1 or 1b* QL candesartan cilexetil oral tablet 4 mg, 8 mg 1 or 1b* DO irbesartan oral tablet 150 mg, 75 mg 1 or 1b* DO irbesartan oral tablet 300 mg 1 or 1b* QL losartan potassium oral tablet 100 mg, 50 mg 1 or 1b* QL losartan potassium oral tablet 25 mg 1 or 1b* DO olmesartan medoxomil oral tablet 20 mg, 5 mg 1 or 1b* DO olmesartan medoxomil oral tablet 40 mg 1 or 1b* QL telmisartan oral tablet 20 mg, 40 mg 1 or 1b* DO telmisartan oral tablet 80 mg 1 or 1b* QL VALSARTAN ORAL SOLUTION 2 PA; QL valsartan oral tablet 160 mg, 320 mg 1 or 1b* QL valsartan oral tablet 40 mg, 80 mg 1 or 1b* DO *ANGIOTENSIN II RECEPTOR ANT-CA CHANNEL BLOCKER- THIAZIDES*** amlodipine-valsartan-hctz oral tablet 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 28