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Xxxxxx Anti-ulcer/Motility Xxxxxx (PPI)
Name AETNA BCBSMA BMCHP FCHP HPHC HNE NHP NTWK MAHLTH THP
OMEPRAzOLE (10 mg) DL PA* DL* PA DL sT NC X DL DL X X 7 DL 1
OMEPRAzOLE [Prilosec (Rx)] DL FE NC DL DL PA NC X NC PA NC DL 1
PA sT PA sT
OMEPRAzOLE (Rx) DL* PA DL* PA DL sT NC X DL DL X 7 DL* 1
OMEPRAzOLE 20mg (Rx) DL PA DL PA* NC X DL X* PA 1 DL* 1
sT
OMEPRAzOLE 20mg OTC NC NC X NC DL X* PA
OMEPRAzOLE suspension [Prilosec] DL PA NC DL NC X X 5 PA NC DL 3
sT PA sT
OMEPRAzOLE MAgNEsIUM
[Prilosec (OTC)]
NC NC X X NC DL NC X*
OMEPRAzOLE/sODIUM DL FE NC DL DL PA NC X NC PA PA NC DL1,3 BICARBONATE [zegerid] PA sT PA sT
PANTOPRAzOLE DL FE NC DL DL PA NC X DL DL sT PA PA DL1 PA PA sT*
PANTOPRAzOLE [Protonix DL FE NC DL DL PA NC X DL DL sT X5 PA NC8 suspension] PA sT PA DL3 sT
PANTOPRAzOLE injection NC6 X X NC NC6 [Protonix IV]
X X X
RABEPRAzOLE [Aciphex] DL FE NC DL DL PA PA X PA PA NC DL1 PA sT PA sT
Asthma Oral Agents
ALBUTEROL X* X* X X X X X X X X
ALBUTEROL ER X* X* X X X X X X X X
ALBUTEROL ER [Vospire ER] X X X NC X
AMINOPHyLLINE X* X* X X X X X X X X
METAPROTERENOL FE X* X X X X X X X X
MONTELUKAsT [singulair] DL* sT* sT sT X X DL sT sT PA9 X*
MONTELUKAsT [singulair]
(for allergies)
DL* NC sT X X sT PA X
TERBUTALINE X* X* X X X X X X X X
THEOPHyLLINE X* X* X X X X X X X X
THEOPHyLLINE [Theo-24] FE X* X X X X X X
zAFIRLUKAsT [Accolate] DL FE NC sT sT PA X X PA9 X
zILEUTON [zyflo CR] DL FE NC sT PA X PA NC
7 20 mg covered; 40 mg requires PA
8 ≥13 yrs old
9 ≥17 yrs old
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