Antacid, H. Pylori

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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
Current Drug Use Criteria New Drug Evaluation
bismuth/metronid/tetracycline PYLERA CAPSULE Y    
bismuth/metronid/tetracycline BISMUTH-METRONIDAZOLE-TETRACYC CAPSULE Y    
lansoprazole/amoxiciln/clarith LANSOPRAZOL-AMOXICIL-CLARITHRO COMBO. PKG Y    
omeprazole/amoxicill/rifabutin TALICIA CAP IR DR N    
omeprazole/clarith/amoxicillin OMECLAMOX-PAK COMBO. PKG N