Antacid, Proton Pump Inhibitors
PDL Reference Documents
- Antacids (Proton Pump Inhibitors and Histamine-2 Receptor Antagonists) - Oct 01, 2020
- Proton Pump Inhibitor/Histamine-2 Receptor Antagonist Scan - May 25, 2017
- Proton Pump Inhibitor/Histamine-2 Receptor Antagonists Class Update - Mar 26, 2015
- Proton Pump Inhibitors DERP Scan - Mar 27, 2014
- Proton Pump Inhibitors Scan Summary - Mar 27, 2014
- Drug Class Review: Proton Pump Inhibitors (PPIs) and Histamine-2 Antagonists (H2A) - Jan 31, 2013
Drug Use Review 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 |
|---|---|---|---|---|---|
| dexlansoprazole | DEXLANSOPRAZOLE DR | CAP DR BP | Y | Quantity Limit | |
| dexlansoprazole | DEXILANT | CAP DR BP | Y | Quantity Limit | |
| lansoprazole | PREVACID | CAPSULE DR | Y | Quantity Limit | |
| lansoprazole | PREVACID 24HR | CAPSULE DR | Y | Quantity Limit | |
| lansoprazole | LANSOPRAZOLE | CAPSULE DR | Y | Quantity Limit | |
| lansoprazole | LANSOPRAZOLE | CAPSULE DR | Y | Quantity Limit | |
| lansoprazole | PREVACID 24HR | CAPSULE DR | Y | Quantity Limit | |
| omeprazole | OMEPRAZOLE | CAPSULE DR | Y | Quantity Limit | |
| pantoprazole sodium | PANTOPRAZOLE SODIUM | TABLET DR | Y | Quantity Limit | |
| pantoprazole sodium | PROTONIX | TABLET DR | Y | Quantity Limit | |
| rabeprazole sodium | RABEPRAZOLE SODIUM | TABLET DR | Y | Quantity Limit | |
| rabeprazole sodium | ACIPHEX | TABLET DR | Y | Quantity Limit | |
| esomeprazole magnesium | NEXIUM | CAPSULE DR | N | Quantity Limit | |
| esomeprazole magnesium | ESOMEPRAZOLE MAGNESIUM | CAPSULE DR | N | Quantity Limit | |
| esomeprazole magnesium | ESOMEPRAZOLE MAGNESIUM | SUSPDR PKT | N | Quantity Limit | |
| esomeprazole magnesium | NEXIUM | SUSPDR PKT | N | Quantity Limit | |
| esomeprazole magnesium | ESOMEPRAZOLE MAGNESIUM | TABLET DR | N | Quantity Limit | |
| lansoprazole | LANSOPRAZOLE | TAB RAP DR | N | Quantity Limit | |
| lansoprazole | PREVACID | TAB RAP DR | N | Quantity Limit | |
| omeprazole | OMEPRAZOLE | TAB RAP DR | N | Quantity Limit | |
| omeprazole | OMEPRAZOLE | TABLET DR | N | Quantity Limit | |
| omeprazole magnesium | OMEPRAZOLE MAGNESIUM | CAPSULE DR | N | Quantity Limit | |
| omeprazole magnesium | ACID REDUCER | CAPSULE DR | N | Quantity Limit | |
| omeprazole magnesium | PRILOSEC | SUSPDR PKT | N | Quantity Limit | |
| omeprazole magnesium | OMEPRAZOLE MAGNESIUM | TABLET DR | N | Quantity Limit | |
| omeprazole/sodium bicarbonate | OMEPRAZOLE-SODIUM BICARBONATE | CAPSULE | N | Quantity Limit | |
| omeprazole/sodium bicarbonate | ZEGERID | CAPSULE | N | Quantity Limit | |
| omeprazole/sodium bicarbonate | OMEPRAZOLE-SODIUM BICARBONATE | PACKET | N | Quantity Limit | |
| omeprazole/sodium bicarbonate | ZEGERID | PACKET | N | Quantity Limit | |
| omeprazole/sodium bicarbonate | KONVOMEP | SUSP RECON | N | Quantity Limit | |
| pantoprazole sodium | PANTOPRAZOLE SODIUM | GRANPKT DR | N | Quantity Limit | |
| pantoprazole sodium | PROTONIX | GRANPKT DR | N | Quantity Limit |