Antacid, Proton Pump Inhibitors
PDL Reference Documents
Drug Use Review Documents
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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.
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 |
|---|---|---|---|---|---|---|
| esomeprazole magnesium | NEXIUM | CAPSULE DR | Y | Quantity Limit | N | |
| esomeprazole magnesium | ESOMEPRAZOLE MAGNESIUM | CAPSULE DR | Y | Quantity Limit | N | |
| esomeprazole magnesium | NEXIUM 24HR | CAPSULE DR | Y | Quantity Limit | N | |
| lansoprazole | ACID REDUCER | CAPSULE DR | Y | Quantity Limit | N | |
| lansoprazole | LANSOPRAZOLE | CAPSULE DR | Y | Quantity Limit | N | |
| lansoprazole | PREVACID | CAPSULE DR | Y | Quantity Limit | N | |
| lansoprazole | LANSOPRAZOLE | CAPSULE DR | Y | Quantity Limit | N | |
| rabeprazole sodium | RABEPRAZOLE SODIUM | TABLET DR | Y | Quantity Limit | N | |
| dexlansoprazole | DEXILANT | CAP DR BP | N | Quantity Limit | N | |
| esomeprazole magnesium | NEXIUM | SUSPDR PKT | N | Quantity Limit | N | |
| esomeprazole magnesium | ESOMEPRAZOLE MAGNESIUM | TABLET DR | N | Quantity Limit | N | |
| omeprazole magnesium | ACID REDUCER | CAPSULE DR | N | Quantity Limit | N | |
| omeprazole magnesium | OMEPRAZOLE MAGNESIUM | TABLET DR | N | Quantity Limit | N | |
| omeprazole/sodium bicarbonate | OMEPRAZOLE-SODIUM BICARBONATE | CAPSULE | N | Quantity Limit | N | |
| omeprazole/sodium bicarbonate | OMEPRAZOLE-SODIUM BICARBONATE | PACKET | N | Quantity Limit | N | |
| pantoprazole sodium | PANTOPRAZOLE SODIUM | GRANPKT DR | N | Quantity Limit | N | |
| pantoprazole sodium | PROTONIX | GRANPKT DR | N | Quantity Limit | N |