Digestants

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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 but eligible patients will encounter a co-pay at the pharmacy.
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
lactase LACTRASE CAPSULE    
lactase SURELAC TAB CHEW    
lactase DAIRY RELIEF TAB CHEW    
lactase LACTASE TABLET    
lactase ULTRA DAIRY DIGESTIVE TABLET    
lactase LACTASE FAST ACTING TABLET    
lactase LAC-DOSE TABLET    
lactase DAIRY RELIEF TABLET    
lactase DAIRY DIGEST TABLET    
lactase DAIRY DIGESTIVE TABLET