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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 49884015124 | BISMUTH-METRONIDAZOLE-TETRACYC | bismuth/metronid/tetracycline | CAPSULE | 140 mg-125 mg-125 mg | Y | Y | |
| 49884015154 | BISMUTH-METRONIDAZOLE-TETRACYC | bismuth/metronid/tetracycline | CAPSULE | 140 mg-125 mg-125 mg | Y | Y | |
| 50742028313 | BISMUTH-METRONIDAZOLE-TETRACYC | bismuth/metronid/tetracycline | CAPSULE | 140 mg-125 mg-125 mg | Y | Y | |
| 61269038512 | BISMUTH-METRONIDAZOLE-TETRACYC | bismuth/metronid/tetracycline | CAPSULE | 140 mg-125 mg-125 mg | Y | Y | |
| 58914060120 | PYLERA | bismuth/metronid/tetracycline | CAPSULE | 140 mg-125 mg-125 mg | Y | Y | |
| 61269038012 | PYLERA | bismuth/metronid/tetracycline | CAPSULE | 140 mg-125 mg-125 mg | Y | Y | |
| 57237000101 | LANSOPRAZOL-AMOXICIL-CLARITHRO | lansoprazole/amoxiciln/clarith | COMBO. PKG | 30 mg-500 mg-500 mg | Y | Y | |
| 57237000114 | LANSOPRAZOL-AMOXICIL-CLARITHRO | lansoprazole/amoxiciln/clarith | COMBO. PKG | 30 mg-500 mg-500 mg | Y | Y | |
| 57841115001 | TALICIA | omeprazole/amoxicill/rifabutin | CAP IR DR | 10 mg-250 mg-12.5 mg | Y | Y | |
| 57841115002 | TALICIA | omeprazole/amoxicill/rifabutin | CAP IR DR | 10 mg-250 mg-12.5 mg | Y | Y | |
| 81520025001 | VOQUEZNA DUAL PAK | vonoprazan/amoxicillin | COMBO. PKG | 20 mg (28)-500 mg (84) | N | Y | PA Document |
| 81520025014 | VOQUEZNA DUAL PAK | vonoprazan/amoxicillin | COMBO. PKG | 20 mg (28)-500 mg (84) | N | Y | PA Document |
| 81520025501 | VOQUEZNA TRIPLE PAK | vonoprazan/amoxicillin/clarith | COMBO. PKG | 20 mg (28)-500 mg (56)-500 mg (28) | N | Y | PA Document |
| 81520025514 | VOQUEZNA TRIPLE PAK | vonoprazan/amoxicillin/clarith | COMBO. PKG | 20 mg (28)-500 mg (56)-500 mg (28) | N | Y | PA Document |