Antacid, H2 Antagonists

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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
famotidine ACID CONTROLLER TABLET Y    
famotidine PEPCID TABLET Y    
famotidine ACID REDUCER TABLET Y    
famotidine FAMOTIDINE TABLET Y    
famotidine HEARTBURN RELIEF TABLET Y    
famotidine ACID CONTROLLER TABLET Y    
famotidine FAMOTIDINE TABLET Y    
famotidine PEPCID AC TABLET Y    
famotidine MYLANTA AR TABLET Y    
famotidine HM ACID REDUCER TABLET Y    
famotidine HEARTBURN PREVENTION TABLET Y    
famotidine ACID REDUCER TABLET Y    
famotidine ACID CONTROL TABLET Y    
ranitidine HCl RANITIDINE HCL SYRUP Y    
ranitidine HCl RANITIDINE HCL TABLET Y    
ranitidine HCl ACID REDUCER TABLET Y    
ranitidine HCl ACID CONTROL TABLET Y    
ranitidine HCl ZANTAC TABLET Y    
ranitidine HCl HEARTBURN RELIEF 150 TABLET Y    
ranitidine HCl HEARTBURN TABLET Y    
ranitidine HCl HEARTBURN RELIEF 75 TABLET Y    
ranitidine HCl ACID CONTROL TABLET Y    
ranitidine HCl RANITIDINE HCL TABLET Y    
ranitidine HCl RANITIDINE TABLET Y    
ranitidine HCl HM ACID REDUCER TABLET Y    
ranitidine HCl HEARTBURN RELIEF TABLET Y    
ranitidine HCl HEARTBURN TABLET Y    
ranitidine HCl WAL-ZAN 75 TABLET Y    
ranitidine HCl ACID REDUCER TABLET Y    
ranitidine HCl ZANTAC TABLET Y    
ranitidine HCl ACID REDUCER 150 TABLET Y    
ranitidine HCl ZANTAC 75 TABLET Y    
ranitidine HCl WAL-ZAN 150 TABLET Y    
cimetidine ACID REDUCER TABLET N    
cimetidine CIMETIDINE TABLET N    
cimetidine HEARTBURN RELIEF TABLET N    
cimetidine HCl CIMETIDINE SOLUTION N    
famotidine PEPCID ORAL SUSP N    
famotidine FAMOTIDINE ORAL SUSP N    
famotidine/Ca carb/mag hydrox COMPLETE TAB CHEW N    
famotidine/Ca carb/mag hydrox ACID REDUCER COMPLETE TAB CHEW N    
nizatidine NIZATIDINE CAPSULE N    
nizatidine NIZATIDINE SOLUTION N    
ranitidine HCl RANITIDINE HCL CAPSULE N