Antacid, Misc

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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 New Drug Evaluation
magnesium oxide MAGNESIUM OXIDE TABLET N    
aluminum hydroxide ALUMINUM HYDROXIDE ORAL SUSP    
calcium carb/magnesium carb SINTRA-ES TABLET    
calcium carb/magnesium carb ANTACID TABLET    
calcium carb/magnesium carb CIDATRINE-TM TABLET    
calcium carb/magnesium hydrox SENTRIVA-ES TAB CHEW    
calcium carbonate/simethicone PHAZYME GAS AND ACID TAB CHEW    
calcium carbonate/simethicone ANTACID-ANTIGAS TAB CHEW    
esomeprazole sodium NEXIUM I.V. VIAL    
esomeprazole sodium ESOMEPRAZOLE SODIUM VIAL    
famotidine FAMOTIDINE VIAL    
famotidine PEPCID VIAL    
famotidine in NaCl,iso-osm/PF FAMOTIDINE PIGGYBACK    
famotidine/PF FAMOTIDINE VIAL    
mag carb/aluminum hydrox/algin HEARTBURN RELIEF ORAL SUSP    
mag carb/aluminum hydrox/algin GAVISCON ORAL SUSP    
mag carb/aluminum hydrox/algin ACID GONE ANTACID ORAL SUSP    
mag hydrox/aluminum hyd/simeth ADVANCED ANTACID-ANTIGAS ORAL SUSP    
mag hydrox/aluminum hyd/simeth ALMACONE-2 ORAL SUSP    
mag hydrox/aluminum hyd/simeth ALUM-MAG HYDROXIDE-SIMETHICONE ORAL SUSP    
mag hydrox/aluminum hyd/simeth ANTACID ORAL SUSP    
mag hydrox/aluminum hyd/simeth ANTACID PLUS ORAL SUSP    
mag hydrox/aluminum hyd/simeth ANTACID-ANTIGAS ORAL SUSP    
mag hydrox/aluminum hyd/simeth GELUSIL ORAL SUSP    
mag hydrox/aluminum hyd/simeth ANTACID W/SIMETHICONE ORAL SUSP    
mag hydrox/aluminum hyd/simeth MAG-AL PLUS ORAL SUSP    
mag hydrox/aluminum hyd/simeth MAG-AL PLUS XS ORAL SUSP    
mag hydrox/aluminum hyd/simeth MINTOX MAXIMUM STRENGTH ORAL SUSP    
mag hydrox/aluminum hyd/simeth MASANTI II ORAL SUSP    
mag hydrox/aluminum hyd/simeth MINTOX PLUS TAB CHEW    
magnesium carb/aluminum hydrox GAVISCON TAB CHEW    
magnesium carb/aluminum hydrox ANTACID EXTRA STRENGTH TAB CHEW    
magnesium carb/aluminum hydrox ACID GONE TAB CHEW    
magnesium, aluminum hydroxide MAG-AL ORAL SUSP    
misoprostol MISOPROSTOL TABLET    
misoprostol CYTOTEC TABLET    
palifermin KEPIVANCE VIAL    
pantoprazole sodium PROTONIX IV VIAL    
pantoprazole sodium PANTOPRAZOLE SODIUM VIAL    
sodium bicarbonate SODIUM BICARBONATE TABLET    
sucralfate CARAFATE ORAL SUSP    
sucralfate SUCRALFATE ORAL SUSP    
sucralfate SUCRALFATE TABLET    
sucralfate CARAFATE TABLET