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Proton Pump Inhibitors (PPIs) Step Therapy with Quantity Limit Program Summary
Policy Number: PH-1068
This step therapy program applies to Blue Partner, Commercial, GenPlus, SourceRx and Health Insurance Marketplace formularies.
Quantity limits apply to Blue Partner, Commercial, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace formularies.
POLICY REVIEW CYCLE
Effective Date |
Date of Origin |
10/1/2023 |
|
FDA APPROVED INDICATIONS AND DOSAGE
Agent(s) |
FDA Indication(s) |
Notes |
Ref# |
Aciphex® Sprinkle™, Rabeprazole Sprinkle (rabeprazole) Capsule |
Treatment of GERD in pediatric patients 1 to 11 years of age for up to 12 weeks |
|
2 |
Aciphex® (rabeprazole) Tablet*
|
|
* generic available |
1 |
Dexilant® (dexlansoprazole)* Capsule |
|
* generic available |
3 |
Esomeprazole Strontium Capsule |
|
|
4 |
Konvomep™ (omeprazole/sodium bicarbonate) Oral suspension |
|
|
16 |
Nexium® (esomeprazole magnesium) Capsule* Suspension packet |
|
* generic available |
5 |
Prevacid®, Prevacid® SoluTab™ (lansoprazole)* Capsule Orally disintegrating tablet (ODT) |
|
* generic available |
6 |
Prilosec® (omeprazole) Capsule* Suspension packet |
|
* generic available |
7 |
Protonix® (pantoprazole) Tablet* Suspension packet |
|
* generic available |
8 |
Zegerid® (omeprazole/sodium bicarbonate) Capsule* Suspension packet |
|
* generic available |
9 |
See package insert for FDA prescribing information: https://dailymed.nlm.nih.gov/dailymed/index.cfm
CLINICAL RATIONALE
Overview |
Current guidelines recognize the proton pump inhibitors (PPIs) as first-line therapy for the management of dyspepsia, gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD), eradication of Helicobacter pylori (H. pylori), and Zollinger Ellison syndrome (ZES).(10-15,17) In studies comparing PPIs to one another, while some differences have been reported, the magnitude of differences (safety/efficacy) has been small and of uncertain clinical importance. The degree to which any differences would justify the selection of one vs. another PPI, particularly when considering cost-effectiveness, is unclear. Data suggests the similar efficacy of PPIs that has been observed in controlled clinical trials may not necessarily translate into equivalent effectiveness when these drugs are substituted for one another. Differences in dosage formulations and drug interactions may occasionally influence choice of PPI in individual cases.(10-13) |
Safety(1-9, 16) |
Aciphex is contraindicated in the following:
Dexilant is contraindicated in the following:
Esomeprazole Strontium is contraindicated in the following:
Konvomep is contraindicated in the following:
Nexium is contraindicated in the following:
Prevacid is contraindicated in the following:
Prilosec is contraindicated in the following:
Protonix is contraindicated in the following:
Zegerid is contraindicated in the following:
|
REFERENCES
Number |
Reference |
1 |
Aciphex prescribing information. Woodward Pharm Services LLC. March 2022. |
2 |
Aciphex Sprinkle prescribing information. Aytu Therapeutics, LLC. December 2020. |
3 |
Dexilant prescribing information. Takeda Pharmaceuticals America, Inc. March 2022. |
4 |
Esomeprazole strontium prescribing information. Amneal Pharmaceuticals LLC. January 2021. |
5 |
Nexium prescribing information. AstraZeneca Pharmaceuticals LP. March 2022. |
6 |
Prevacid prescribing information. Takeda Pharmaceuticals America, Inc. Prevacid 2022. |
7 |
Prilosec delayed-release suspension prescribing information. Covis Pharma. March 2022. |
8 |
Protonix prescribing information. Wyeth Pharmaceuticals LLC. November 2020. |
9 |
Zegerid prescribing information. Santarus Inc. March 2022. |
10 |
Katz PO, Dunbar KB, Schnoll-Sussman FH, et al. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. The American Journal of Gastroenterology. 2022;117(1):27-56. |
11 |
Drugs for GERD and peptic ulcer disease. Medical Letter Treatment Guidelines. 2022;64(1647):49-56. |
12 |
Laine L, Barkun A, Saltzman J, et al. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding The American Journal of Gastroenterology 116(5):p 899-917, May 2021. |
13 |
Shaheen N, Falk G, Iyer P, et al. ACG Clinical Guideline: Diagnosis and Management of Barrett’s Esophagus. American Journal of Gastroenterology 111(1):p 30-50, January 2016. |
14 |
The Zollinger-Ellison syndrome: dangers and consequences of interrupting antisecretory treatment. Clinical Gastroenterology and Hepatology. 2012 Feb;10(2):199-202. |
15 |
Zollinger-Ellison syndrome: classical considerations and current controversies. The Oncologist. 2014 Jan;19(1):44-50. |
16 |
Konvomep prescribing information. Azuirty Pharmaceuticals, Inc. December 2022. |
17 |
Chey W, Leontiadis G, Howden CW & Moss, S. F. Correction: ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. The American Journal of Gastroenterology, 113(7), 1102, 2018 https://doi.org/10.1038/s41395-018-0132-6 |
POLICY AGENT SUMMARY STEP THERAPY
Agent Names |
Strength |
Targeted MSC |
Available MSC |
Final Age Limit |
Preferred Status |
|
|||||
ESOMEPRAZOLE*esomeprazole strontium cap delayed release |
49.3 MG |
M ; N ; O |
N |
|
|
OMEPRAZOLE*omeprazole cap delayed release |
10 MG ; 20 ; 20 MG ; 40 MG |
M ; N ; O |
Y |
|
|
ACIPHEX*rabeprazole sodium ec tab ; RABEPRAZOLE*rabeprazole sodium ec tab |
20 MG |
M ; N ; O |
O ; Y |
|
|
ACIPHEX*rabeprazole sodium capsule sprinkle dr ; RABEPRAZOLE*rabeprazole sodium capsule sprinkle dr |
10 MG ; 5 MG |
M ; N ; O |
M ; N |
|
|
CVS*esomeprazole magnesium cap delayed release ; EQ*esomeprazole magnesium cap delayed release ; ESOMEPRAZOLE*esomeprazole magnesium cap delayed release ; GNP*esomeprazole magnesium cap delayed release ; GOODSENSE*esomeprazole magnesium cap delayed release ; HM*esomeprazole magnesium cap delayed release ; KLS*esomeprazole magnesium cap delayed release ; NEXIUM*esomeprazole magnesium cap delayed release ; QC*esomeprazole magnesium cap delayed release ; RA*esomeprazole magnesium cap delayed release ; SM*esomeprazole magnesium cap delayed release |
20 ; 20 MG ; 40 MG |
M ; N ; O |
O ; Y |
|
|
CVS*lansoprazole cap delayed release ; EQ*lansoprazole cap delayed release ; EQL*lansoprazole cap delayed release ; GNP*lansoprazole cap delayed release ; GOODSENSE*lansoprazole cap delayed release ; HM*lansoprazole cap delayed release ; KLS*lansoprazole cap delayed release ; LANSOPRAZOLE*lansoprazole cap delayed release ; PREVACID*lansoprazole cap delayed release ; QC*lansoprazole cap delayed release ; SM*lansoprazole cap delayed release |
15 MG ; 30 MG |
M ; N ; O |
O ; Y |
|
|
CVS*lansoprazole tab delayed release orally disintegrating ; LANSOPRAZOLE*lansoprazole tab delayed release orally disintegrating ; PREVACID*lansoprazole tab delayed release orally disintegrating |
15 MG ; 30 MG |
M ; N ; O |
O ; Y |
|
|
CVS*omeprazole-sodium bicarbonate cap ; OMEPRAZOLE/SODIUM*omeprazole-sodium bicarbonate cap ; ZEGERID*omeprazole-sodium bicarbonate cap |
20-1100 MG ; 40-1100 MG |
M ; N ; O |
O ; Y |
|
|
DEXILANT*dexlansoprazole cap delayed release ; DEXLANSOPRAZOLE*dexlansoprazole cap delayed release |
30 MG ; 60 MG |
M ; N ; O |
O ; Y |
|
|
KONVOMEP*omeprazole-sodium bicarbonate for oral susp |
2-84 MG/ML |
M ; N ; O |
N |
|
|
ESOMEPRAZOLE*esomeprazole magnesium for delayed release susp packet ; NEXIUM*esomeprazole magnesium for delayed release susp pack ; NEXIUM*esomeprazole magnesium for delayed release susp packet |
10 MG ; 2.5 MG ; 20 MG ; 40 MG ; 5 MG |
M ; N ; O |
N ; O ; Y |
|
|
ESOMEPRAZOLE*esomeprazole magnesium tab delayed release ; NEXIUM*esomeprazole magnesium tab delayed release |
20 MG |
M ; N ; O |
O ; Y |
|
|
PRILOSEC*omeprazole magnesium for delayed release susp packet |
10 MG ; 2.5 MG |
M ; N ; O |
N |
|
|
PRILOSEC*Omeprazole Magnesium For Delayed Release Susp Packet 10 MG |
10 MG |
M ; N ; O |
N |
|
|
PRILOSEC*Omeprazole Magnesium For Delayed Release Susp Packet 2.5 MG |
2.5 MG |
M ; N ; O |
N |
|
|
PANTOPRAZOLE*pantoprazole sodium ec tab ; PROTONIX*pantoprazole sodium ec tab |
20 ; 20 MG ; 40 MG |
M ; N ; O |
O ; Y |
|
|
PANTOPRAZOLE*pantoprazole sodium for delayed release susp packet ; PROTONIX*pantoprazole sodium for delayed release susp packet |
40 MG |
M ; N ; O |
O ; Y |
|
|
OMEPRAZOLE/SODIUM*omeprazole-sodium bicarbonate powd pack for susp ; ZEGERID*omeprazole-sodium bicarbonate powd pack for susp |
20-1680 MG ; 40-1680 MG |
M ; N ; O |
O ; Y |
|
|
POLICY AGENT SUMMARY QUANTITY LIMIT
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
QL Amount |
Dose Form |
Day Supply |
Duration |
Addtl QL Info |
Allowed Exceptions |
Targeted NDCs When Exclusions Exist |
|
|||||||||
|
esomeprazole strontium cap delayed release |
49.3 MG |
30 |
Capsules |
30 |
DAYS |
|
"1. Hypersecretory disease (i.e., Zollinger-Ellison Syndrome), Barrett?s esophagitis, or esophageal stricture - approve 12 months OR 2. Conventional therapy failure (failure of standard labeled dosing with the requested agent) - approve 12 months OR 3. H pylori treatment - approve once" |
|
|
omeprazole cap delayed release |
10 MG ; 20 ; 20 MG ; 40 MG |
30 |
Capsules |
30 |
DAYS |
|
"1. Hypersecretory disease (i.e., Zollinger-Ellison Syndrome), Barrett?s esophagitis, or esophageal stricture - approve 12 months OR 2. Conventional therapy failure (failure of standard labeled dosing with the requested agent) - approve 12 months OR 3. H pylori treatment - approve once" |
|
|
Omeprazole Cap Delayed Release 40 MG |
40 MG |
30 |
Capsules |
30 |
DAYS |
Smart QL: 1 capsule daily for 30 days; 2 capsules daily thereafter |
"1. Hypersecretory disease (i.e., Zollinger-Ellison Syndrome), Barrett's esophagitis, or esophageal stricture - approve 12 months OR 2. Conventional therapy failure (failure of standard labeled dosing with the requested agent) - approve 12 months OR 3. H pylori treatment - approve once" |
|
Aciphex |
rabeprazole sodium ec tab |
20 MG |
30 |
Tablets |
30 |
DAYS |
|
"1. Hypersecretory disease (i.e., Zollinger-Ellison Syndrome), Barrett?s esophagitis, or esophageal stricture - approve 12 months OR 2. Conventional therapy failure (failure of standard labeled dosing with the requested agent) - approve 12 months OR 3. H pylori treatment - approve once" |
|
Aciphex sprinkle |
rabeprazole sodium capsule sprinkle dr |
10 MG ; 5 MG |
30 |
Capsules |
30 |
DAYS |
|
"1. Hypersecretory disease (i.e., Zollinger-Ellison Syndrome), Barrett?s esophagitis, or esophageal stricture - approve 12 months OR 2. Conventional therapy failure (failure of standard labeled dosing with the requested agent) - approve 12 months OR 3. H pylori treatment - approve once" |
|
Cvs esomeprazole magnesiu ; Eq esomeprazole magnesium ; Gnp esomeprazole magnesiu ; Goodsense esomeprazole ma ; Hm esomeprazole magnesium ; Kls esomeprazole magnesiu ; Nexium ; Nexium 24hr ; Nexium 24hr clear minis ; Qc esomeprazole magnesium ; Ra esomeprazole magnesium ; Sm esomeprazole magnesium |
esomeprazole magnesium cap delayed release |
20 ; 20 MG ; 40 MG |
30 |
Capsules |
30 |
DAYS |
|
"1. Hypersecretory disease (i.e., Zollinger-Ellison Syndrome), Barrett?s esophagitis, or esophageal stricture - approve 12 months OR 2. Conventional therapy failure (failure of standard labeled dosing with the requested agent) - approve 12 months OR 3. H pylori treatment - approve once" |
|
Cvs lansoprazole ; Eq lansoprazole ; Eql lansoprazole ; Gnp lansoprazole ; Goodsense lansoprazole ; Hm lansoprazole ; Kls lansoprazole ; Prevacid ; Prevacid 24hr ; Qc lansoprazole ; Sm lansoprazole |
lansoprazole cap delayed release |
15 MG ; 30 MG |
30 |
Capsules |
30 |
DAYS |
|
"1. Hypersecretory disease (i.e., Zollinger-Ellison Syndrome), Barrett?s esophagitis, or esophageal stricture - approve 12 months OR 2. Conventional therapy failure (failure of standard labeled dosing with the requested agent) - approve 12 months OR 3. H pylori treatment - approve once" |
|
Cvs lansoprazole ; Prevacid solutab |
lansoprazole tab delayed release orally disintegrating |
15 MG ; 30 MG |
30 |
Tablets |
30 |
DAYS |
|
"1. Hypersecretory disease (i.e., Zollinger-Ellison Syndrome), Barrett?s esophagitis, or esophageal stricture - approve 12 months OR 2. Conventional therapy failure (failure of standard labeled dosing with the requested agent) - approve 12 months OR 3. H pylori treatment - approve once" |
|
Cvs omeprazole/sodium bic ; Zegerid |
omeprazole-sodium bicarbonate cap |
20-1100 MG ; 40-1100 MG |
30 |
Capsules |
30 |
DAYS |
|
"1. Hypersecretory disease (i.e., Zollinger-Ellison Syndrome), Barrett?s esophagitis, or esophageal stricture - approve 12 months OR 2. Conventional therapy failure (failure of standard labeled dosing with the requested agent) - approve 12 months OR 3. H pylori treatment - approve once" |
|
Dexilant |
dexlansoprazole cap delayed release |
30 MG ; 60 MG |
30 |
Capsules |
30 |
DAYS |
|
"1. Hypersecretory disease (i.e., Zollinger-Ellison Syndrome), Barrett?s esophagitis, or esophageal stricture - approve 12 months OR 2. Conventional therapy failure (failure of standard labeled dosing with the requested agent) - approve 12 months OR 3. H pylori treatment - approve once" |
|
Konvomep |
omeprazole-sodium bicarbonate for oral susp |
2-84 MG/ML |
600 |
mLs |
30 |
DAYS |
|
|
|
Nexium |
esomeprazole magnesium for delayed release susp pack ; esomeprazole magnesium for delayed release susp packet |
10 MG ; 2.5 MG ; 20 MG ; 40 MG ; 5 MG |
30 |
Packets |
30 |
DAYS |
|
"1. Hypersecretory disease (i.e., Zollinger-Ellison Syndrome), Barrett?s esophagitis, or esophageal stricture - approve 12 months OR 2. Conventional therapy failure (failure of standard labeled dosing with the requested agent) - approve 12 months OR 3. H pylori treatment - approve once" |
|
Nexium 24hr |
esomeprazole magnesium tab delayed release |
20 MG |
30 |
Tablets |
30 |
DAYS |
|
"1. Hypersecretory disease (i.e., Zollinger-Ellison Syndrome), Barrett?s esophagitis, or esophageal stricture - approve 12 months OR 2. Conventional therapy failure (failure of standard labeled dosing with the requested agent) - approve 12 months OR 3. H pylori treatment - approve once" |
|
Prilosec |
Omeprazole Magnesium For Delayed Release Susp Packet 10 MG |
10 MG |
30 |
Packets |
30 |
DAYS |
|
"1. Hypersecretory disease (i.e., Zollinger-Ellison Syndrome), Barrett's esophagitis, or esophageal stricture - approve 12 months OR 2. Conventional therapy failure (failure of standard labeled dosing with the requested agent) - approve 12 months OR 3. H pylori treatment - approve once" |
|
Prilosec |
Omeprazole Magnesium For Delayed Release Susp Packet 2.5 MG |
2.5 MG |
60 |
Packets |
30 |
DAYS |
|
"1. Hypersecretory disease (i.e., Zollinger-Ellison Syndrome), Barrett's esophagitis, or esophageal stricture - approve 12 months OR 2. Conventional therapy failure (failure of standard labeled dosing with the requested agent) - approve 12 months OR 3. H pylori treatment - approve once" |
|
Protonix |
pantoprazole sodium ec tab |
20 ; 20 MG ; 40 MG |
30 |
Tablets |
30 |
DAYS |
|
"1. Hypersecretory disease (i.e., Zollinger-Ellison Syndrome), Barrett?s esophagitis, or esophageal stricture - approve 12 months OR 2. Conventional therapy failure (failure of standard labeled dosing with the requested agent) - approve 12 months OR 3. H pylori treatment - approve once" |
|
Protonix |
Pantoprazole Sodium EC Tab 40 MG (Base Equiv) |
40 MG |
30 |
Tablets |
30 |
DAYS |
Smart QL: 1 tablet daily for 30 days; 2 tablets daily thereafter |
"1. Hypersecretory disease (i.e., Zollinger-Ellison Syndrome), Barrett's esophagitis, or esophageal stricture - approve 12 months OR 2. Conventional therapy failure (failure of standard labeled dosing with the requested agent) - approve 12 months OR 3. H pylori treatment - approve once" |
|
Protonix |
pantoprazole sodium for delayed release susp packet |
40 MG |
30 |
Packets |
30 |
DAYS |
|
"1. Hypersecretory disease (i.e., Zollinger-Ellison Syndrome), Barrett?s esophagitis, or esophageal stricture - approve 12 months OR 2. Conventional therapy failure (failure of standard labeled dosing with the requested agent) - approve 12 months OR 3. H pylori treatment - approve once" |
|
Zegerid |
omeprazole-sodium bicarbonate powd pack for susp |
20-1680 MG ; 40-1680 MG |
30 |
Packets |
30 |
DAYS |
|
"1. Hypersecretory disease (i.e., Zollinger-Ellison Syndrome), Barrett?s esophagitis, or esophageal stricture - approve 12 months OR 2. Conventional therapy failure (failure of standard labeled dosing with the requested agent) - approve 12 months OR 3. H pylori treatment - approve once" |
|
CLIENT SUMMARY – STEP THERAPY
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
|
esomeprazole strontium cap delayed release |
49.3 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; SourceRx |
|
omeprazole cap delayed release |
10 MG ; 20 ; 20 MG ; 40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; SourceRx |
Aciphex |
rabeprazole sodium ec tab |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; SourceRx |
Aciphex sprinkle |
rabeprazole sodium capsule sprinkle dr |
10 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; SourceRx |
Cvs esomeprazole magnesiu ; Eq esomeprazole magnesium ; Gnp esomeprazole magnesiu ; Goodsense esomeprazole ma ; Hm esomeprazole magnesium ; Kls esomeprazole magnesiu ; Nexium ; Nexium 24hr ; Nexium 24hr clear minis ; Qc esomeprazole magnesium ; Ra esomeprazole magnesium ; Sm esomeprazole magnesium |
esomeprazole magnesium cap delayed release |
20 ; 20 MG ; 40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; SourceRx |
Cvs lansoprazole ; Eq lansoprazole ; Eql lansoprazole ; Gnp lansoprazole ; Goodsense lansoprazole ; Hm lansoprazole ; Kls lansoprazole ; Prevacid ; Prevacid 24hr ; Qc lansoprazole ; Sm lansoprazole |
lansoprazole cap delayed release |
15 MG ; 30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; SourceRx |
Cvs lansoprazole ; Prevacid solutab |
lansoprazole tab delayed release orally disintegrating |
15 MG ; 30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; SourceRx |
Cvs omeprazole/sodium bic ; Zegerid |
omeprazole-sodium bicarbonate cap |
20-1100 MG ; 40-1100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; SourceRx |
Dexilant |
dexlansoprazole cap delayed release |
30 MG ; 60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; SourceRx |
Konvomep |
omeprazole-sodium bicarbonate for oral susp |
2-84 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; SourceRx |
Nexium |
esomeprazole magnesium for delayed release susp pack ; esomeprazole magnesium for delayed release susp packet |
10 MG ; 2.5 MG ; 20 MG ; 40 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; SourceRx |
Nexium 24hr |
esomeprazole magnesium tab delayed release |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; SourceRx |
Prilosec |
omeprazole magnesium for delayed release susp packet |
10 MG ; 2.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; SourceRx |
Prilosec |
Omeprazole Magnesium For Delayed Release Susp Packet 10 MG |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; SourceRx |
Prilosec |
Omeprazole Magnesium For Delayed Release Susp Packet 2.5 MG |
2.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; SourceRx |
Protonix |
pantoprazole sodium ec tab |
20 ; 20 MG ; 40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; SourceRx |
Protonix |
pantoprazole sodium for delayed release susp packet |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; SourceRx |
Zegerid |
omeprazole-sodium bicarbonate powd pack for susp |
20-1680 MG ; 40-1680 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; SourceRx |
CLIENT SUMMARY – QUANTITY LIMITS
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
|
esomeprazole strontium cap delayed release |
49.3 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
omeprazole cap delayed release |
10 MG ; 20 ; 20 MG ; 40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Omeprazole Cap Delayed Release 40 MG |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Aciphex |
rabeprazole sodium ec tab |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Aciphex sprinkle |
rabeprazole sodium capsule sprinkle dr |
10 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Cvs esomeprazole magnesiu ; Eq esomeprazole magnesium ; Gnp esomeprazole magnesiu ; Goodsense esomeprazole ma ; Hm esomeprazole magnesium ; Kls esomeprazole magnesiu ; Nexium ; Nexium 24hr ; Nexium 24hr clear minis ; Qc esomeprazole magnesium ; Ra esomeprazole magnesium ; Sm esomeprazole magnesium |
esomeprazole magnesium cap delayed release |
20 ; 20 MG ; 40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Cvs lansoprazole ; Eq lansoprazole ; Eql lansoprazole ; Gnp lansoprazole ; Goodsense lansoprazole ; Hm lansoprazole ; Kls lansoprazole ; Prevacid ; Prevacid 24hr ; Qc lansoprazole ; Sm lansoprazole |
lansoprazole cap delayed release |
15 MG ; 30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Cvs lansoprazole ; Prevacid solutab |
lansoprazole tab delayed release orally disintegrating |
15 MG ; 30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Cvs omeprazole/sodium bic ; Zegerid |
omeprazole-sodium bicarbonate cap |
20-1100 MG ; 40-1100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Dexilant |
dexlansoprazole cap delayed release |
30 MG ; 60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Konvomep |
omeprazole-sodium bicarbonate for oral susp |
2-84 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Nexium |
esomeprazole magnesium for delayed release susp pack ; esomeprazole magnesium for delayed release susp packet |
10 MG ; 2.5 MG ; 20 MG ; 40 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Nexium 24hr |
esomeprazole magnesium tab delayed release |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Prilosec |
Omeprazole Magnesium For Delayed Release Susp Packet 10 MG |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Prilosec |
Omeprazole Magnesium For Delayed Release Susp Packet 2.5 MG |
2.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Protonix |
pantoprazole sodium ec tab |
20 ; 20 MG ; 40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Protonix |
Pantoprazole Sodium EC Tab 40 MG (Base Equiv) |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Protonix |
pantoprazole sodium for delayed release susp packet |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zegerid |
omeprazole-sodium bicarbonate powd pack for susp |
20-1680 MG ; 40-1680 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
STEP THERAPY CLINICAL CRITERIA FOR APPROVAL
Module |
Clinical Criteria for Approval |
||||||
|
* - generic available Target Agent(s) will be approved when ONE of the following is met:
Length of Approval: 12 months NOTE: If Quantity Limit applies, please refer to Quantity Limit criteria
|
QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL
Module |
Clinical Criteria for Approval |
|
Quantity limit for the Target Agent(s) will be approved when ONE of the following is met:
Length of Approval: up to 12 months
|
This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.
Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.
Commercial _ PS _ Proton Pump Inhibitors (PPIs) _STQL _ProgSum_ 10/1/2023