Antacid, Misc

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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 but eligible patients will encounter a co-pay at the pharmacy.
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 New Drug Evaluation
CALCIUM CARBONATE CALCIUM CARBONATE TABLET Y    
CALCIUM CARBONATE CALCIUM CARBONATE TABLET Y    
CALCIUM CARBONATE TUMS TAB CHEW N    
CALCIUM CARBONATE ANTACID TAB CHEW N    
CALCIUM CARBONATE ANTACID EXTRA STRENGTH TAB CHEW N    
CALCIUM CARBONATE ANTACID CALCIUM TAB CHEW N    
CALCIUM CARBONATE CALCIUM ANTACID TAB CHEW N    
CALCIUM CARBONATE TUMS X-STR TAB CHEW N    
CALCIUM CARBONATE TUMS SMOOTHIES TAB CHEW N    
ALUMINUM HYDROXIDE ALUMINUM HYDROXIDE ORAL SUSP    
CALCIUM CARB/MAGNESIUM HYDROX MI-ACID DS TAB CHEW    
CALCIUM CARB/MAGNESIUM HYDROX ANTACID TAB CHEW    
CALCIUM CARBONATE TUMS ULTRA TAB CHEW    
CALCIUM CARBONATE CALCIUM ANTACID TAB CHEW    
CALCIUM CARBONATE ANTACID TAB CHEW    
CALCIUM CARBONATE CAL-GEST TAB CHEW    
CALCIUM CARBONATE TUMS ULTRA STRENGTH TAB CHEW    
CALCIUM CARBONATE TUMS TAB CHEW    
CALCIUM CARBONATE TUMS FRESHERS TAB CHEW    
CALCIUM CARBONATE/SIMETHICONE ANTACID-ANTIGAS TAB CHEW    
ESOMEPRAZOLE SODIUM NEXIUM I.V. VIAL    
ESOMEPRAZOLE SODIUM ESOMEPRAZOLE SODIUM VIAL    
FAMOTIDINE FAMOTIDINE VIAL    
FAMOTIDINE IN NACL,ISO-OSM/PF FAMOTIDINE PIGGYBACK    
FAMOTIDINE/PF FAMOTIDINE VIAL    
MAG CARB/ALUMINUM HYDROX/ALGIN GAVISCON ORAL SUSP    
MAG CARB/ALUMINUM HYDROX/ALGIN ACID GONE ANTACID ORAL SUSP    
MAG HYDROX/ALUMINUM HYD/SIMETH ANTACID PLUS ANTI-GAS ORAL SUSP    
MAG HYDROX/ALUMINUM HYD/SIMETH ANTACID ANTI-GAS DOUBLE STR ORAL SUSP    
MAG HYDROX/ALUMINUM HYD/SIMETH ANTACID MAXIMUM STRENGTH ORAL SUSP    
MAG HYDROX/ALUMINUM HYD/SIMETH RULOX ORAL SUSP    
MAG HYDROX/ALUMINUM HYD/SIMETH MINTOX MAXIMUM STRENGTH ORAL SUSP    
MAG HYDROX/ALUMINUM HYD/SIMETH MINTOX ORAL SUSP    
MAG HYDROX/ALUMINUM HYD/SIMETH MI-ACID ORAL SUSP    
MAG HYDROX/ALUMINUM HYD/SIMETH MI ACID ORAL SUSP    
MAG HYDROX/ALUMINUM HYD/SIMETH MASANTI ORAL SUSP    
MAG HYDROX/ALUMINUM HYD/SIMETH MAG-AL PLUS XS ORAL SUSP    
MAG HYDROX/ALUMINUM HYD/SIMETH ALMACONE-2 ORAL SUSP    
MAG HYDROX/ALUMINUM HYD/SIMETH ALMACONE ORAL SUSP    
MAG HYDROX/ALUMINUM HYD/SIMETH ADVANCED ANTACID-ANTIGAS ORAL SUSP    
MAG HYDROX/ALUMINUM HYD/SIMETH ADVANCED ANTACID ORAL SUSP    
MAG HYDROX/ALUMINUM HYD/SIMETH LIQUID ANTACID ORAL SUSP    
MAG HYDROX/ALUMINUM HYD/SIMETH ANTACID-ANTIGAS ORAL SUSP    
MAG HYDROX/ALUMINUM HYD/SIMETH ANTACID WITH SIMETHICONE ORAL SUSP    
MAG HYDROX/ALUMINUM HYD/SIMETH ANTACID ORAL SUSP    
MAG HYDROX/ALUMINUM HYD/SIMETH MAG-AL PLUS ORAL SUSP    
MAG HYDROX/ALUMINUM HYD/SIMETH MINTOX PLUS TAB CHEW    
MAG HYDROX/ALUMINUM HYD/SIMETH ALMACONE TAB CHEW    
MAG/ALUMINUM/SOD BICARB/ALGINC GAVISCON TAB CHEW    
MAGNESIUM CARB/ALUMINUM HYDROX GAVISCON TAB CHEW    
MAGNESIUM CARB/ALUMINUM HYDROX ANTACID EXTRA STRENGTH TAB CHEW    
MAGNESIUM CARB/ALUMINUM HYDROX ACID GONE TAB CHEW    
MAGNESIUM, ALUMINUM HYDROXIDE MAG-AL ORAL SUSP    
MISOPROSTOL CYTOTEC TABLET    
MISOPROSTOL MISOPROSTOL TABLET    
PALIFERMIN KEPIVANCE VIAL    
PANTOPRAZOLE SODIUM PROTONIX IV VIAL    
PANTOPRAZOLE SODIUM PANTOPRAZOLE SODIUM VIAL    
RANITIDINE HCL ZANTAC VIAL    
RANITIDINE HCL RANITIDINE HCL VIAL    
SODIUM BICARBONATE SODIUM BICARBONATE TABLET    
SUCRALFATE SUCRALFATE ORAL SUSP    
SUCRALFATE CARAFATE ORAL SUSP    
SUCRALFATE SUCRALFATE TABLET    
SUCRALFATE CARAFATE TABLET