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 PEPCID AC TABLET Y    
FAMOTIDINE ACID CONTROLLER TABLET Y    
FAMOTIDINE ACID REDUCER TABLET Y    
FAMOTIDINE HEARTBURN PREVENTION TABLET Y    
FAMOTIDINE FAMOTIDINE TABLET Y    
FAMOTIDINE ACID CONTROL TABLET Y    
FAMOTIDINE ACID CONTROLLER TABLET Y    
FAMOTIDINE ACID REDUCER TABLET Y    
FAMOTIDINE FAMOTIDINE TABLET Y    
FAMOTIDINE HEARTBURN RELIEF TABLET Y    
FAMOTIDINE PEPCID TABLET Y    
RANITIDINE HCL RANITIDINE HCL SYRUP Y    
RANITIDINE HCL WAL-ZAN 75 TABLET Y    
RANITIDINE HCL RANITIDINE HCL TABLET Y    
RANITIDINE HCL ZANTAC TABLET Y    
RANITIDINE HCL ZANTAC 75 TABLET Y    
RANITIDINE HCL ZANTAC TABLET Y    
RANITIDINE HCL WAL-ZAN 150 TABLET Y    
RANITIDINE HCL RANITIDINE HCL TABLET Y    
RANITIDINE HCL HEARTBURN RELIEF TABLET Y    
RANITIDINE HCL ACID REDUCER 150 TABLET Y    
RANITIDINE HCL ACID CONTROL TABLET Y    
RANITIDINE HCL RANITIDINE TABLET Y    
RANITIDINE HCL ACID REDUCER TABLET Y    
RANITIDINE HCL HEARTBURN RELIEF 150 TABLET Y    
RANITIDINE HCL ACID REDUCER TABLET Y    
RANITIDINE HCL ACID CONTROL TABLET Y    
CIMETIDINE HEARTBURN RELIEF TABLET N    
CIMETIDINE ACID REDUCER TABLET N    
CIMETIDINE CIMETIDINE TABLET N    
CIMETIDINE HCL CIMETIDINE SOLUTION N    
FAMOTIDINE FAMOTIDINE ORAL SUSP N    
FAMOTIDINE PEPCID 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