Antacid, Misc
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 |
|---|---|---|---|---|---|---|
| magnesium oxide | MAGNESIUM OXIDE | TABLET | N | |||
| aluminum hydroxide | ALUMINUM HYDROXIDE | ORAL SUSP | ||||
| calcium carb/magnesium carb | ANTACID | TABLET | ||||
| calcium carb/magnesium hydrox | SENTRIVA-ES | TAB CHEW | ||||
| calcium carbonate/simethicone | PHAZYME GAS AND ACID | TAB CHEW | ||||
| 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 | ACID GONE ANTACID | ORAL SUSP | ||||
| mag carb/aluminum hydrox/algin | HEARTBURN RELIEF | ORAL SUSP | ||||
| mag carb/aluminum hydrox/algin | GAVISCON | ORAL SUSP | ||||
| mag hydrox/aluminum hyd/simeth | ANTACID | ORAL SUSP | ||||
| mag hydrox/aluminum hyd/simeth | GELUSIL | ORAL SUSP | ||||
| mag hydrox/aluminum hyd/simeth | ANTACID-ANTIGAS | ORAL SUSP | ||||
| mag hydrox/aluminum hyd/simeth | ANTACID PLUS | ORAL SUSP | ||||
| mag hydrox/aluminum hyd/simeth | ALUM-MAG HYDROXIDE-SIMETHICONE | ORAL SUSP | ||||
| mag hydrox/aluminum hyd/simeth | MAG-AL PLUS | ORAL SUSP | ||||
| mag hydrox/aluminum hyd/simeth | ANTACID W/SIMETHICONE | ORAL SUSP | ||||
| mag hydrox/aluminum hyd/simeth | MAG-AL PLUS XS | ORAL SUSP | ||||
| mag hydrox/aluminum hyd/simeth | MASANTI II | ORAL SUSP | ||||
| mag hydrox/aluminum hyd/simeth | MINTOX MAXIMUM STRENGTH | ORAL SUSP | ||||
| mag hydrox/aluminum hyd/simeth | ALMACONE-2 | ORAL SUSP | ||||
| mag hydrox/aluminum hyd/simeth | MINTOX PLUS | TAB CHEW | ||||
| magnesium carb/aluminum hydrox | ACID GONE | TAB CHEW | ||||
| magnesium carb/aluminum hydrox | GAVISCON | TAB CHEW | ||||
| magnesium carb/aluminum hydrox | ANTACID EXTRA STRENGTH | TAB CHEW | ||||
| magnesium, aluminum hydroxide | MAG-AL | ORAL SUSP | ||||
| misoprostol | MISOPROSTOL | TABLET | ||||
| misoprostol | CYTOTEC | TABLET | ||||
| palifermin | KEPIVANCE | VIAL | ||||
| pantoprazole in 0.9% sod chlor | PANTOPRAZOLE SODIUM-0.9% NACL | FROZ.PIGGY | ||||
| pantoprazole sodium | PANTOPRAZOLE SODIUM | VIAL | ||||
| pantoprazole sodium | PROTONIX IV | VIAL | ||||
| sodium bicarbonate | SODIUM BICARBONATE | TABLET | ||||
| sucralfate | SUCRALFATE | ORAL SUSP | ||||
| sucralfate | SUCRALFATE | TABLET | ||||
| sucralfate | CARAFATE | TABLET |