Antacid, Misc

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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.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
00536009185 ALUMINUM HYDROXIDE aluminum hydroxide ORAL SUSP 320 mg/5 mL Y N  
00113015972 ANTACID calcium carb/magnesium carb TABLET 311 mg-232 mg Y N  
83035620203 SENTRIVA-ES calcium carb/magnesium hydrox TAB CHEW 975 mg-232 mg Y N  
46122015175 ANTACID-ANTIGAS calcium carbonate/simethicone TAB CHEW 1,000 mg-60 mg Y N  
00132000507 PHAZYME GAS AND ACID calcium carbonate/simethicone TAB CHEW 750 mg-250 mg Y N  
70436019080 ESOMEPRAZOLE SODIUM esomeprazole sodium VIAL 40 mg Y N  
70436019082 ESOMEPRAZOLE SODIUM esomeprazole sodium VIAL 40 mg Y N  
00641602101 FAMOTIDINE famotidine VIAL 10 mg/mL Y N  
00641602110 FAMOTIDINE famotidine VIAL 10 mg/mL Y N  
00641602301 FAMOTIDINE famotidine VIAL 10 mg/mL Y N  
00641602310 FAMOTIDINE famotidine VIAL 10 mg/mL Y N  
63323073803 FAMOTIDINE famotidine VIAL 10 mg/mL Y N  
63323073806 FAMOTIDINE famotidine VIAL 10 mg/mL Y N  
63323073809 FAMOTIDINE famotidine VIAL 10 mg/mL Y N  
63323073820 FAMOTIDINE famotidine VIAL 10 mg/mL Y N  
67457044800 FAMOTIDINE famotidine VIAL 10 mg/mL Y N  
67457044843 FAMOTIDINE famotidine VIAL 10 mg/mL Y N  
67457045700 FAMOTIDINE famotidine VIAL 10 mg/mL Y N  
67457045720 FAMOTIDINE famotidine VIAL 10 mg/mL Y N  
70860075341 FAMOTIDINE famotidine VIAL 10 mg/mL Y N  
00006354120 PEPCID famotidine VIAL 10 mg/mL Y N  
00338519741 FAMOTIDINE famotidine in NaCl,iso-osm/PF PIGGYBACK 20 mg/50 mL Y N  
00641602201 FAMOTIDINE famotidine/PF VIAL 20 mg/2 mL Y N  
00641602225 FAMOTIDINE famotidine/PF VIAL 20 mg/2 mL Y N  
25021075302 FAMOTIDINE famotidine/PF VIAL 20 mg/2 mL Y N  
63323073911 FAMOTIDINE famotidine/PF VIAL 20 mg/2 mL Y N  
63323073912 FAMOTIDINE famotidine/PF VIAL 20 mg/2 mL Y N  
63323073916 FAMOTIDINE famotidine/PF VIAL 20 mg/2 mL Y N  
63323073941 FAMOTIDINE famotidine/PF VIAL 20 mg/2 mL Y N  
67457043300 FAMOTIDINE famotidine/PF VIAL 20 mg/2 mL Y N  
67457043322 FAMOTIDINE famotidine/PF VIAL 20 mg/2 mL Y N  
70860075102 FAMOTIDINE famotidine/PF VIAL 20 mg/2 mL Y N  
70860075141 FAMOTIDINE famotidine/PF VIAL 20 mg/2 mL Y N  
00088117312 GAVISCON mag carb/aluminum hydrox/algin ORAL SUSP 237.5 mg-254 mg/5 mL Y N  
70000036301 HEARTBURN RELIEF mag carb/aluminum hydrox/algin ORAL SUSP 237.5 mg-254 mg/5 mL Y N  
00904772714 ACID GONE ANTACID mag carb/aluminum hydrox/algin ORAL SUSP 358 mg-95 mg/15 mL Y N  
00088117112 GAVISCON mag carb/aluminum hydrox/algin ORAL SUSP 358 mg-95 mg/15 mL Y N  
00904732562 ALUM-MAG HYDROXIDE-SIMETHICONE mag hydrox/aluminum hyd/simeth ORAL SUSP 200 mg-200 mg-20 mg/5 mL Y N  
00904732573 ALUM-MAG HYDROXIDE-SIMETHICONE mag hydrox/aluminum hyd/simeth ORAL SUSP 200 mg-200 mg-20 mg/5 mL Y N  
00904755762 ALUM-MAG HYDROXIDE-SIMETHICONE mag hydrox/aluminum hyd/simeth ORAL SUSP 200 mg-200 mg-20 mg/5 mL Y N  
00904755773 ALUM-MAG HYDROXIDE-SIMETHICONE mag hydrox/aluminum hyd/simeth ORAL SUSP 200 mg-200 mg-20 mg/5 mL Y N  
57237031603 ALUM-MAG HYDROXIDE-SIMETHICONE mag hydrox/aluminum hyd/simeth ORAL SUSP 200 mg-200 mg-20 mg/5 mL Y N  
57237031631 ALUM-MAG HYDROXIDE-SIMETHICONE mag hydrox/aluminum hyd/simeth ORAL SUSP 200 mg-200 mg-20 mg/5 mL Y N  
60687087745 ALUM-MAG HYDROXIDE-SIMETHICONE mag hydrox/aluminum hyd/simeth ORAL SUSP 200 mg-200 mg-20 mg/5 mL Y N  
60687087776 ALUM-MAG HYDROXIDE-SIMETHICONE mag hydrox/aluminum hyd/simeth ORAL SUSP 200 mg-200 mg-20 mg/5 mL Y N  
46122043340 ANTACID mag hydrox/aluminum hyd/simeth ORAL SUSP 200 mg-200 mg-20 mg/5 mL Y N  
00113037640 ANTACID W/SIMETHICONE mag hydrox/aluminum hyd/simeth ORAL SUSP 200 mg-200 mg-20 mg/5 mL Y N  
00536129383 ANTACID-ANTIGAS mag hydrox/aluminum hyd/simeth ORAL SUSP 200 mg-200 mg-20 mg/5 mL Y N  
00536131783 ANTACID-ANTIGAS mag hydrox/aluminum hyd/simeth ORAL SUSP 200 mg-200 mg-20 mg/5 mL Y N  
46122043440 ANTACID-ANTIGAS mag hydrox/aluminum hyd/simeth ORAL SUSP 200 mg-200 mg-20 mg/5 mL Y N  
49348002097 ANTACID-ANTIGAS mag hydrox/aluminum hyd/simeth ORAL SUSP 200 mg-200 mg-20 mg/5 mL Y N  
70000006301 ANTACID-ANTIGAS mag hydrox/aluminum hyd/simeth ORAL SUSP 200 mg-200 mg-20 mg/5 mL Y N  
70677106301 ANTACID-ANTIGAS mag hydrox/aluminum hyd/simeth ORAL SUSP 200 mg-200 mg-20 mg/5 mL Y N  
70677106601 ANTACID-ANTIGAS mag hydrox/aluminum hyd/simeth ORAL SUSP 200 mg-200 mg-20 mg/5 mL Y N  
83324012112 ANTACID-ANTIGAS mag hydrox/aluminum hyd/simeth ORAL SUSP 200 mg-200 mg-20 mg/5 mL Y N  
00121176130 MAG-AL PLUS mag hydrox/aluminum hyd/simeth ORAL SUSP 200 mg-200 mg-20 mg/5 mL Y N  
63739015910 MAG-AL PLUS mag hydrox/aluminum hyd/simeth ORAL SUSP 200 mg-200 mg-20 mg/5 mL Y N  
63739015977 MAG-AL PLUS mag hydrox/aluminum hyd/simeth ORAL SUSP 200 mg-200 mg-20 mg/5 mL Y N  
00071203622 GELUSIL mag hydrox/aluminum hyd/simeth ORAL SUSP 200 mg-200 mg-25 mg/5 mL Y N  
00113031940 ANTACID PLUS mag hydrox/aluminum hyd/simeth ORAL SUSP 200 mg-225 mg-25 mg/5 mL Y N  
00536001583 ALMACONE-2 mag hydrox/aluminum hyd/simeth ORAL SUSP 400 mg-400 mg-40 mg/5 mL Y N  
00904732662 ALUM-MAG HYDROXIDE-SIMETHICONE mag hydrox/aluminum hyd/simeth ORAL SUSP 400 mg-400 mg-40 mg/5 mL Y N  
57237032403 ALUM-MAG HYDROXIDE-SIMETHICONE mag hydrox/aluminum hyd/simeth ORAL SUSP 400 mg-400 mg-40 mg/5 mL Y N  
57237032431 ALUM-MAG HYDROXIDE-SIMETHICONE mag hydrox/aluminum hyd/simeth ORAL SUSP 400 mg-400 mg-40 mg/5 mL Y N  
60687088845 ALUM-MAG HYDROXIDE-SIMETHICONE mag hydrox/aluminum hyd/simeth ORAL SUSP 400 mg-400 mg-40 mg/5 mL Y N  
60687088876 ALUM-MAG HYDROXIDE-SIMETHICONE mag hydrox/aluminum hyd/simeth ORAL SUSP 400 mg-400 mg-40 mg/5 mL Y N  
00113034035 ANTACID W/SIMETHICONE mag hydrox/aluminum hyd/simeth ORAL SUSP 400 mg-400 mg-40 mg/5 mL Y N  
46122043140 ANTACID-ANTIGAS mag hydrox/aluminum hyd/simeth ORAL SUSP 400 mg-400 mg-40 mg/5 mL Y N  
46122043240 ANTACID-ANTIGAS mag hydrox/aluminum hyd/simeth ORAL SUSP 400 mg-400 mg-40 mg/5 mL Y N  
70000006201 ANTACID-ANTIGAS mag hydrox/aluminum hyd/simeth ORAL SUSP 400 mg-400 mg-40 mg/5 mL Y N  
70000042201 ANTACID-ANTIGAS mag hydrox/aluminum hyd/simeth ORAL SUSP 400 mg-400 mg-40 mg/5 mL Y N  
70677106401 ANTACID-ANTIGAS mag hydrox/aluminum hyd/simeth ORAL SUSP 400 mg-400 mg-40 mg/5 mL Y N  
70677106501 ANTACID-ANTIGAS mag hydrox/aluminum hyd/simeth ORAL SUSP 400 mg-400 mg-40 mg/5 mL Y N  
83324012212 ANTACID-ANTIGAS mag hydrox/aluminum hyd/simeth ORAL SUSP 400 mg-400 mg-40 mg/5 mL Y N  
00121176230 MAG-AL PLUS XS mag hydrox/aluminum hyd/simeth ORAL SUSP 400 mg-400 mg-40 mg/5 mL Y N  
00113030840 MASANTI II mag hydrox/aluminum hyd/simeth ORAL SUSP 400 mg-400 mg-40 mg/5 mL Y N  
00904572514 MINTOX MAXIMUM STRENGTH mag hydrox/aluminum hyd/simeth ORAL SUSP 400 mg-400 mg-40 mg/5 mL Y N  
00904670060 MINTOX PLUS mag hydrox/aluminum hyd/simeth TAB CHEW 200 mg-200 mg-25 mg Y N  
00904536560 ACID GONE magnesium carb/aluminum hydrox TAB CHEW 105 mg-160 mg Y N  
46122015078 ANTACID EXTRA STRENGTH magnesium carb/aluminum hydrox TAB CHEW 105 mg-160 mg Y N  
70000023401 ANTACID EXTRA STRENGTH magnesium carb/aluminum hydrox TAB CHEW 105 mg-160 mg Y N  
00088117447 GAVISCON magnesium carb/aluminum hydrox TAB CHEW 105 mg-160 mg Y N  
28595071040 MAGNESIUM OXIDE magnesium oxide TABLET 265.3 mg magnesium (440 mg) N Y N  
83035182301 MAGNESIUM OXIDE magnesium oxide TABLET 300 mg magnesium N Y N  
00603020922 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg N Y N  
24689013201 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg N Y N  
58657012012 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg N Y N  
69367029820 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg N Y N  
81033002712 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg N Y N  
63739005802 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg (241.3 mg magnesium) N Y N  
64980033901 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg (241.3 mg magnesium) N Y N  
64980033912 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg (241.3 mg magnesium) N Y N  
64980033990 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg (241.3 mg magnesium) N Y N  
69367027102 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg (241.3 mg magnesium) N Y N  
71800001301 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg (241.3 mg magnesium) N Y N  
83035182201 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg (241.3 mg magnesium) N Y N  
83035182205 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg (241.3 mg magnesium) N Y N  
83592025905 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg (241.3 mg magnesium) N Y N  
85633004030 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg (241.3 mg magnesium) N Y N  
85633004036 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg (241.3 mg magnesium) N Y N  
00603021321 MAGNESIUM OXIDE magnesium oxide TABLET 420 mg N Y N  
00904423960 MAGNESIUM OXIDE magnesium oxide TABLET 500 mg magnesium Y N  
00121176030 MAG-AL magnesium, aluminum hydroxide ORAL SUSP 200 mg-200 mg/5 mL Y N  
00025145134 CYTOTEC misoprostol TABLET 100 mcg Y N  
00025145160 CYTOTEC misoprostol TABLET 100 mcg Y N  
59762500701 MISOPROSTOL misoprostol TABLET 100 mcg Y N  
59762500702 MISOPROSTOL misoprostol TABLET 100 mcg Y N  
60687073501 MISOPROSTOL misoprostol TABLET 100 mcg Y N  
60687073511 MISOPROSTOL misoprostol TABLET 100 mcg Y N  
70954044310 MISOPROSTOL misoprostol TABLET 100 mcg Y N  
70954044320 MISOPROSTOL misoprostol TABLET 100 mcg Y N  
00025146131 CYTOTEC misoprostol TABLET 200 mcg Y N  
00025146160 CYTOTEC misoprostol TABLET 200 mcg Y N  
43393002304 MISOPROSTOL misoprostol TABLET 200 mcg Y N  
43393002404 MISOPROSTOL misoprostol TABLET 200 mcg Y N  
43393020004 MISOPROSTOL misoprostol TABLET 200 mcg Y N  
43393020048 MISOPROSTOL misoprostol TABLET 200 mcg Y N  
43393020060 MISOPROSTOL misoprostol TABLET 200 mcg Y N  
50268055560 MISOPROSTOL misoprostol TABLET 200 mcg Y N  
59762500801 MISOPROSTOL misoprostol TABLET 200 mcg Y N  
59762500802 MISOPROSTOL misoprostol TABLET 200 mcg Y N  
60687074601 MISOPROSTOL misoprostol TABLET 200 mcg Y N  
60687074611 MISOPROSTOL misoprostol TABLET 200 mcg Y N  
63704000801 MISOPROSTOL misoprostol TABLET 200 mcg Y N  
70954044410 MISOPROSTOL misoprostol TABLET 200 mcg Y N  
70954044420 MISOPROSTOL misoprostol TABLET 200 mcg Y N  
66658011301 KEPIVANCE palifermin VIAL 5.16 mg Y N  
66658011303 KEPIVANCE palifermin VIAL 5.16 mg Y N  
66658011306 KEPIVANCE palifermin VIAL 5.16 mg Y N  
00338964401 PANTOPRAZOLE SODIUM-0.9% NACL pantoprazole in 0.9% sod chlor FROZ.PIGGY 40 mg/100 mL (0.4 mg/mL) Y N  
00338964412 PANTOPRAZOLE SODIUM-0.9% NACL pantoprazole in 0.9% sod chlor FROZ.PIGGY 40 mg/100 mL (0.4 mg/mL) Y N  
00338964601 PANTOPRAZOLE SODIUM-0.9% NACL pantoprazole in 0.9% sod chlor FROZ.PIGGY 40 mg/50 mL (0.8 mg/mL) Y N  
00338964624 PANTOPRAZOLE SODIUM-0.9% NACL pantoprazole in 0.9% sod chlor FROZ.PIGGY 40 mg/50 mL (0.8 mg/mL) Y N  
00338964801 PANTOPRAZOLE SODIUM-0.9% NACL pantoprazole in 0.9% sod chlor FROZ.PIGGY 80 mg/100 mL (0.8 mg/mL) Y N  
00338964812 PANTOPRAZOLE SODIUM-0.9% NACL pantoprazole in 0.9% sod chlor FROZ.PIGGY 80 mg/100 mL (0.8 mg/mL) Y N  
00143928401 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
00143928410 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
00143930001 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
00143930010 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
25021075110 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
25021075111 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
31722020410 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
31722020431 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
55150020200 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
55150020210 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
62332007101 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
62332007110 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
62756012940 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
62756012944 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
65219038501 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
65219038510 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
65219043301 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
65219043315 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
66794025802 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
66794025841 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
70095002401 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
70095002402 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
70095002403 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
71288060010 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
71288060011 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
71839012201 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
71839012210 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
71839012225 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
72572055001 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
72572055010 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
72572055301 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
72572055310 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
72603012801 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
72603012810 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
73043002001 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
73043002010 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
73043002025 PANTOPRAZOLE SODIUM pantoprazole sodium VIAL 40 mg Y N  
00008092351 PROTONIX IV pantoprazole sodium VIAL 40 mg Y N  
00008092355 PROTONIX IV pantoprazole sodium VIAL 40 mg Y N  
00008092360 PROTONIX IV pantoprazole sodium VIAL 40 mg Y N  
00008400101 PROTONIX IV pantoprazole sodium VIAL 40 mg Y N  
00008400110 PROTONIX IV pantoprazole sodium VIAL 40 mg Y N  
00008400125 PROTONIX IV pantoprazole sodium VIAL 40 mg Y N  
00536104610 SODIUM BICARBONATE sodium bicarbonate TABLET 325 mg Y N  
45861008010 SODIUM BICARBONATE sodium bicarbonate TABLET 325 mg Y N  
00536104710 SODIUM BICARBONATE sodium bicarbonate TABLET 650 mg Y N  
00904726161 SODIUM BICARBONATE sodium bicarbonate TABLET 650 mg Y N  
24689013701 SODIUM BICARBONATE sodium bicarbonate TABLET 650 mg Y N  
45861008110 SODIUM BICARBONATE sodium bicarbonate TABLET 650 mg Y N  
64980052810 SODIUM BICARBONATE sodium bicarbonate TABLET 650 mg Y N  
69367025810 SODIUM BICARBONATE sodium bicarbonate TABLET 650 mg Y N  
58914017014 CARAFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
00121097400 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
00121097410 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
00121097440 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
00121097450 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
00121097494 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
00378920535 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
00713079175 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
00904747001 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
00904747018 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
00904747056 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
00904747066 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
00904747072 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
00904747095 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
13668075442 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
50268074511 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
50268074514 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
50742038642 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
52817084016 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
60687073808 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
60687073823 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
60687073842 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
60687073856 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
63739019351 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
63739019372 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
64380014901 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
65162006205 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
66689030516 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
68094004159 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
68094004161 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
68094004162 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
69339020901 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
69339020917 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
69339020919 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
81033014910 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
81033014944 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
81033014952 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
82182010614 SUCRALFATE sucralfate ORAL SUSP 1 gram/10 mL Y N  
58914017110 CARAFATE sucralfate TABLET 1 gram Y N  
00093221001 SUCRALFATE sucralfate TABLET 1 gram Y N  
00093221005 SUCRALFATE sucralfate TABLET 1 gram Y N  
00093221098 SUCRALFATE sucralfate TABLET 1 gram Y N  
51079075301 SUCRALFATE sucralfate TABLET 1 gram Y N  
51079075320 SUCRALFATE sucralfate TABLET 1 gram Y N  
59762040101 SUCRALFATE sucralfate TABLET 1 gram Y N  
59762040105 SUCRALFATE sucralfate TABLET 1 gram Y N  
60219165601 SUCRALFATE sucralfate TABLET 1 gram Y N  
60687069501 SUCRALFATE sucralfate TABLET 1 gram Y N  
60687069511 SUCRALFATE sucralfate TABLET 1 gram Y N  
62135043601 SUCRALFATE sucralfate TABLET 1 gram Y N  
62135043690 SUCRALFATE sucralfate TABLET 1 gram Y N  
69238165601 SUCRALFATE sucralfate TABLET 1 gram Y N  
72578008101 SUCRALFATE sucralfate TABLET 1 gram Y N  
72578008105 SUCRALFATE sucralfate TABLET 1 gram Y N  
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