To order additional copies, please call Massachusetts Medical

Xxxxxx Anti-ulcer/Motility Xxxxxx (Miscellaneous)
Name AETNA BCBSMA BMCHP FCHP HPHC HNE NHP NTWK MAHLTH THP
HyOsCyAMINE X* X* X X X X X X X
LUBIPROsTONE [Amitiza] FE PA PA PA PA X PA PA PA
METHyLNALTREXONE BROMIDE
[Relistor]
DL PA X* PA X X
METOCLOPRAMIDE X* X* X X X X X X X X
METOCLOPRAMIDE ODT [Metozolv] sT NC NC X NC NC
MIsOPROsTOL X* X* X X X X X X X X
sUCRALFATE X* X* X X X X X X X X
TETRACyCLINE/BIsMUTH/
METRONIDAzOLE [Helidac]
DL FE X* PA PA X X PA X
TETRACyCLINE/BIsMUTH/
METRONIDAzOLE [Pylera]
DL* X* PA PA X X PA X
URsODIOL X* X* X X X X X X X X
URsODIOL [Urso/Urso Forte] X* X X X X NC X X
Anti-ulcer/Motility (PPI)
DEXLANsOPRAzOLE [Dexilant] DL PA* NC DL X X PA NC DL1 PA sT
EsOMEPRAzOLE [Nexium] DL PA* NC DL DL sT PA X PA PA NC DL1 PA sT
EsOMEPRAzOLE DL PA* NC DL PA X PA PA NC2 DL3 [Nexium suspension] PA sT
LANsOPRAzOLE DL FE NC DL NC X NC PA PA DL* 1 sT
PA sT* PA
LANsOPRAzOLE [Prevacid] DL FE NC DL DL PA NC X NC PA PA4 NC DL1 PA sT PA sT
LANsOPRAzOLE [Prevacid soluTab] DL PA DL PA NC X X5 PA NC2 DL1 sT
LANsOPRAzOLE [Prevacid OTC] NC NC X NC DL X* PA
LANsOPRAzOLE injection NC6 X X NC X6 [Prevacid IV]
PA X
LANsOPRAzOLE/CLARITHROMyCIN/
AMOXICILLIN KIT [PrevPac]
DL FE DL* PA DL X X PA X
1 90 caps/90 days or 90 tabs/90 days
2 ≥13 yrs old
3 90 packets/90 days
4 ≥2 yrs old
5 >13 yrs old requires PA
6 Not covered under pharmacy benefit; may be covered under medical benefit
22