H2 Antagonists G Cimetidine solution G Ranitidine ZANTAC (150MG TABLETS) G,ST Ranitidine ZANTAC SYRUP ST- Requires prior claim for Cimetidine Soln Other Anti-Ulcer Agents G Sucralfate CARAFATE TABLETS Proton Pump Inhibitors G Omeprazole PRILOSEC * G,ST Pantoprazole PROTONIX * G, PA Lansoprazole PREVACID* PREVACID OTC* Lansoprazole ST- Requires prior claim for Omeprazole * PA required after 6 months continued use of all formulary and non-formulary PPIs Miscellaneous G Chlorhexidine Gluconate PERIDEX G Hydrocortisone hemorrhoid cream, supp PROCTO-CREAM Pramoxine/HC PROCTOFOAM-HC, ANALPRAM-HC, Hydrocortisone intrarectal foam CORTIFOAM Mesalamine G Mesalamine ROWASA enema G Ursodiol ACTIGALL G Misoprostol CYTOTEC G Mesalamine ASPRISO
H2 Antagonists G Cimetidine solution G G,ST ST- Ranitidine Ranitidine Requires prior claim for Cimetidine Soln ZANTAC (150MG TABLETS) ZANTAC SYRUP Other Anti-Ulcer Agents G Sucralfate CARAFATE TABLETS Proton Pump Inhibitors G Omeprazole PRILOSEC * G,ST G, PA Pantoprazole Lansoprazole Lansoprazole PROTONIX * PREVACID* PREVACID OTC* ST- Requires prior claim for Omeprazole * PA required after 6 months continued use of all formulary and non-formulary PPIs Miscellaneous G Chlorhexidine Gluconate PERIDEX G Hydrocortisone hemorrhoid cream, supp PROCTO-CREAM Pramoxine/HC PROCTOFOAM-HC, ANALPRAM-HC, Hydrocortisone intrarectal foam CORTIFOAM Mesalamine G Mesalamine ROWASA enema G Ursodiol ACTIGALL G G Misoprostol Mesalamine CYTOTEC ASPRISO