Antacid, Proton Pump Inhibitors

← Back to Class List

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
omeprazole OMEPRAZOLE CAPSULE DR Y Quantity Limit  
omeprazole ZANTAC-PPI CAPSULE DR Y Quantity Limit  
pantoprazole sodium PROTONIX TABLET DR Y Quantity Limit  
pantoprazole sodium PANTOPRAZOLE SODIUM TABLET DR Y Quantity Limit  
dexlansoprazole DEXILANT CAP DR BP N Quantity Limit  
esomeprazole magnesium NEXIUM CAPSULE DR N Quantity Limit  
esomeprazole magnesium ESOMEPRAZOLE MAGNESIUM CAPSULE DR N Quantity Limit  
esomeprazole magnesium NEXIUM SUSPDR PKT N Quantity Limit  
esomeprazole strontium ESOMEPRAZOLE STRONTIUM CAPSULE DR N Quantity Limit  
lansoprazole PREVACID 24HR CAPSULE DR N Quantity Limit  
lansoprazole PREVACID CAPSULE DR N Quantity Limit  
lansoprazole LANSOPRAZOLE CAPSULE DR N Quantity Limit  
lansoprazole HEARTBURN TREATMENT 24 HOUR CAPSULE DR N Quantity Limit  
lansoprazole PREVACID TAB RAP DR N Quantity Limit  
omeprazole OMEPRAZOLE TABLET DR N Quantity Limit  
omeprazole magnesium OMEPRAZOLE MAGNESIUM CAPSULE DR N Quantity Limit  
omeprazole magnesium ACID REDUCER CAPSULE DR N Quantity Limit  
omeprazole magnesium PRILOSEC SUSPDR PKT N Quantity Limit  
omeprazole/sodium bicarbonate ZEGERID CAPSULE N Quantity Limit  
omeprazole/sodium bicarbonate OMEPRAZOLE-SODIUM BICARBONATE CAPSULE N Quantity Limit  
omeprazole/sodium bicarbonate ZEGERID PACKET N Quantity Limit  
omeprazole/sodium bicarbonate OMEPRAZOLE-SODIUM BICARBONATE PACKET N Quantity Limit  
pantoprazole sodium PROTONIX GRANPKT DR N Quantity Limit  
rabeprazole sodium ACIPHEX SPRINKLE CAP DR SPR N Quantity Limit  
rabeprazole sodium RABEPRAZOLE SODIUM TABLET DR N Quantity Limit  
rabeprazole sodium ACIPHEX TABLET DR N Quantity Limit