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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-00433 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
Last revised April 19, 2024