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Anti-Ulcer Medications

PHARM-13 Statement of Medical Necessity for Quantity Limits Override.

Anti-Ulcer Medications

Drugs

Quantity Limits

Aciphex (Rabeprazole Sodium) 20mg Tablets

 30 Tablets per 30 Days
Kapidex (Dexlansoprazole) 30mg and 60mg Capsules 30 Capsules per 30 Days
Nexium (Esomeprazole Mag Trihydrate) 20mg and 40mg Capsules  30 Capsules per 30 Days
Nexium (Esomeprazole Mag Trihydrate) 10mg, 20mg and 40mg Packets  30 Packets per 30 Days

Prevacid (Lansoprazole) 15mg and 30mg Capsules

 30 Capsules per 30 Days
Prevacid (Lansoprazole) 15mg and 30mg Rapdis Tablets  30 Tablets per 30 Days
Prilosec (Omeprazole) Capsules 10mg - 60 Capsules per 30 Days
20mg - 120 Capsules per 30 Days
40mg - 60 Capsules per 30 Days
Prilosec (Omeprazole Magnesium) 2.5mg and 10mg Packets  30 Packets per 30 Days

Protonix (Pantoprazole Sodium) 20mg and 40mg Tablets

 30 Tablets per 30 Days

Protonix (Pantoprazole Sodium) 40mg Packets 

 30 Packets per 30 Days
Protonix IV (Pantoprazole Sodium) 40mg Vial  10mls per 10 Days

Zegerid (Omeprazole - Sodium Bicarbonate) 20mg - 1.1G and 40mg - 1.1G Capsules 

 30 Capsules per 30 Days

Zegerid (Omeprazole - Sodium Bicarbonate) 20mg - 1680mg and 40mg - 1680mg Packets 

 30 Packets per 30 Days
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Oklahoma Health Care Authority

4345 N Lincoln Blvd

Oklahoma City, OK 73105

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