Displaying 1 - 50 of 288 records found.

Items in this class
Brand Name/Generic Name NDC code Clinical Prior Auth Required PDL Prior Auth Required
ACIPHEX DR 20 MG TABLET
rabeprazole sodium
62856024330 No Yes
ACIPHEX SPRINKLE DR 10 MG CAP
rabeprazole sodium
13551021001 No Yes
ACIPHEX SPRINKLE DR 10 MG CAP
rabeprazole sodium
23594021001 No Yes
ACIPHEX SPRINKLE DR 5 MG CAP
rabeprazole sodium
13551020501 No Yes
ACIPHEX SPRINKLE DR 5 MG CAP
rabeprazole sodium
23594020501 No Yes
DEXILANT DR 30 MG CAPSULE
dexlansoprazole
64764017130 No Yes
DEXILANT DR 60 MG CAPSULE
dexlansoprazole
64764017530 No Yes
ESOMEPRAZOLE MAG DR 20 MG CAP
esomeprazole magnesium
55111049230 Yes Yes
ESOMEPRAZOLE MAG DR 20 MG CAP
esomeprazole magnesium
00093645056 Yes Yes
ESOMEPRAZOLE MAG DR 20 MG CAP
esomeprazole magnesium
00093645098 Yes Yes
ESOMEPRAZOLE MAG DR 20 MG CAP
esomeprazole magnesium
31722057210 Yes Yes
ESOMEPRAZOLE MAG DR 20 MG CAP
esomeprazole magnesium
31722057230 Yes Yes
ESOMEPRAZOLE MAG DR 20 MG CAP
esomeprazole magnesium
31722057290 Yes Yes
ESOMEPRAZOLE MAG DR 20 MG CAP
esomeprazole magnesium
13668015410 Yes Yes
ESOMEPRAZOLE MAG DR 20 MG CAP
esomeprazole magnesium
00186038230 Yes Yes
ESOMEPRAZOLE MAG DR 20 MG CAP
esomeprazole magnesium
00536113113 Yes Yes
ESOMEPRAZOLE MAG DR 20 MG CAP
esomeprazole magnesium
13668015430 Yes Yes
ESOMEPRAZOLE MAG DR 20 MG CAP
esomeprazole magnesium
00186038290 Yes Yes
ESOMEPRAZOLE MAG DR 20 MG CAP
esomeprazole magnesium
00536113171 Yes Yes
ESOMEPRAZOLE MAG DR 20 MG CAP
esomeprazole magnesium
13668015490 Yes Yes
ESOMEPRAZOLE MAG DR 20 MG CAP
esomeprazole magnesium
42292000916 Yes Yes
ESOMEPRAZOLE MAG DR 20 MG CAP
esomeprazole magnesium
00536113188 Yes Yes
ESOMEPRAZOLE MAG DR 20 MG CAP
esomeprazole magnesium
43598050910 Yes Yes
ESOMEPRAZOLE MAG DR 20 MG CAP
esomeprazole magnesium
43598050930 Yes Yes
ESOMEPRAZOLE MAG DR 20 MG CAP
esomeprazole magnesium
43598050990 Yes Yes
ESOMEPRAZOLE MAG DR 20 MG CAP
esomeprazole magnesium
16714073501 Yes Yes
ESOMEPRAZOLE MAG DR 20 MG CAP
esomeprazole magnesium
16714073502 Yes Yes
ESOMEPRAZOLE MAG DR 20 MG CAP
esomeprazole magnesium
65862078330 Yes Yes
ESOMEPRAZOLE MAG DR 20 MG CAP
esomeprazole magnesium
65862078390 Yes Yes
ESOMEPRAZOLE MAG DR 20 MG CAP
esomeprazole magnesium
00378235093 Yes Yes
ESOMEPRAZOLE MAG DR 40 MG CAP
esomeprazole magnesium
00904658168 No Yes
ESOMEPRAZOLE MAG DR 40 MG CAP
esomeprazole magnesium
55111049330 No Yes
ESOMEPRAZOLE MAG DR 40 MG CAP
esomeprazole magnesium
00093645156 No Yes
ESOMEPRAZOLE MAG DR 40 MG CAP
esomeprazole magnesium
00093645198 No Yes
ESOMEPRAZOLE MAG DR 40 MG CAP
esomeprazole magnesium
31722057310 No Yes
ESOMEPRAZOLE MAG DR 40 MG CAP
esomeprazole magnesium
31722057330 No Yes
ESOMEPRAZOLE MAG DR 40 MG CAP
esomeprazole magnesium
31722057390 No Yes
ESOMEPRAZOLE MAG DR 40 MG CAP
esomeprazole magnesium
00186038430 No Yes
ESOMEPRAZOLE MAG DR 40 MG CAP
esomeprazole magnesium
13668015510 No Yes
ESOMEPRAZOLE MAG DR 40 MG CAP
esomeprazole magnesium
00186038490 No Yes
ESOMEPRAZOLE MAG DR 40 MG CAP
esomeprazole magnesium
42292001016 No Yes
ESOMEPRAZOLE MAG DR 40 MG CAP
esomeprazole magnesium
13668015530 No Yes
ESOMEPRAZOLE MAG DR 40 MG CAP
esomeprazole magnesium
13668015590 No Yes
ESOMEPRAZOLE MAG DR 40 MG CAP
esomeprazole magnesium
43598051010 No Yes
ESOMEPRAZOLE MAG DR 40 MG CAP
esomeprazole magnesium
43598051030 No Yes
ESOMEPRAZOLE MAG DR 40 MG CAP
esomeprazole magnesium
43598051090 No Yes
ESOMEPRAZOLE MAG DR 40 MG CAP
esomeprazole magnesium
16714073601 No Yes
ESOMEPRAZOLE MAG DR 40 MG CAP
esomeprazole magnesium
16714073602 No Yes
ESOMEPRAZOLE MAG DR 40 MG CAP
esomeprazole magnesium
65862078430 No Yes
ESOMEPRAZOLE MAG DR 40 MG CAP
esomeprazole magnesium
00378235193 No Yes