Antacid, H. Pylori
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 | 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 | ||
| vonoprazan/amoxicillin | VOQUEZNA DUAL PAK | COMBO. PKG | N | ||
| vonoprazan/amoxicillin/clarith | VOQUEZNA TRIPLE PAK | COMBO. PKG | N |