Antacid, H2 Antagonists
PDL Reference Documents
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.
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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| famotidine | FAMOTIDINE | TABLET | Y | N | ||
| famotidine | ZANTAC-360 (FAMOTIDINE) | TABLET | Y | N | ||
| famotidine | HEARTBURN PREVENTION | TABLET | Y | N | ||
| famotidine | ACID CONTROLLER | TABLET | Y | N | ||
| famotidine | FAMOTIDINE | TABLET | Y | N | ||
| famotidine/Ca carb/mag hydrox | ACID REDUCER-ANTACID | TAB CHEW | Y | N | ||
| famotidine/Ca carb/mag hydrox | DUAL ACTION COMPLETE | TAB CHEW | Y | N | ||
| famotidine/Ca carb/mag hydrox | DUAL ACTION | TAB CHEW | Y | N | ||
| famotidine/Ca carb/mag hydrox | PEPCID COMPLETE | TAB CHEW | Y | N | ||
| famotidine/Ca carb/mag hydrox | TUMS DUAL ACTION | TAB CHEW | Y | N | ||
| ranitidine HCl | ZANTAC | SYRUP | Y | N | ||
| ranitidine HCl | ZANTAC 75 | TABLET | Y | N | ||
| ranitidine HCl | ACID REDUCER | TABLET | Y | N | ||
| cimetidine HCl | CIMETIDINE | SOLUTION | N | N | ||
| cimetidine HCl | CIMETIDINE HCL | SOLUTION | N | N | ||
| famotidine | PEPCID RPD | TAB RAPDIS | N | N |