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Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets

Assigned number Title Release date File type Language Available to order
F-00433 Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets 07/01/2022 PDF English No
F-00433A Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets Instructions 07/01/2022 PDF English No
F-00433 Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets 07/01/2022 Word English No

Glossary

 
Last revised February 21, 2026