Antacid, Proton Pump Inhibitors

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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
OMEPRAZOLE OMEPRAZOLE 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 LANSOPRAZOLE CAPSULE DR N Quantity Limit  
LANSOPRAZOLE HEARTBURN TREATMENT 24 HOUR CAPSULE DR N Quantity Limit  
LANSOPRAZOLE PREVACID CAPSULE DR N Quantity Limit  
LANSOPRAZOLE PREVACID 24HR 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 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