Effective Date
|
Date of Origin
|
04-01-2024
|
|
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*
|
- Healing of erosive or ulcerative gastroesophageal reflux disease (GERD) in adults
- Maintenance of healing of erosive or ulcerative GERD in adults
- Treatment of symptomatic GERD in adults and adolescents 12 years of age and older
- Healing of duodenal ulcers in adults
- Helicobacter pylori eradication to reduce the risk of duodenal ulcer recurrence in adults
- Treatment of pathological hypersecretory conditions, including Zollinger-Ellison syndrome in adults
|
* generic available
|
1
|
Dexilant®
(dexlansoprazole)*
Capsule
|
- Healing of erosive esophagitis in patients 12 years of age and older
- Maintenance of healed erosive esophagitis and relief of heartburn in patients 12 years of age and older
- Treatment of symptomatic non-erosive GERD in patients 12 years of age and older
|
* generic available
|
3
|
Esomeprazole Strontium
Capsule
|
- Treatment of gastroesophageal reflux disease (GERD) in adults
- Risk reduction of NSAID-associated gastric ulcer in adults
- H. pylori eradication to reduce the risk of duodenal ulcer recurrence in adults
- Pathological hypersecretory conditions, including Zollinger-Ellison syndrome in adults
|
|
4
|
Konvomep™
(omeprazole/sodium bicarbonate)
Oral suspension
|
- Treatment of active benign gastric ulcer
- Reduction of risk of upper gastrointestinal (GI) bleeding in critically ill patients
|
|
16
|
Nexium®
(esomeprazole magnesium)
Capsule*
Suspension packet
|
- Treatment of GERD
- Risk reduction of NSAID-associated gastric ulcer
- H. pylori eradication to reduce the risk of duodenal ulcer recurrence
- Pathological hypersecretory conditions, including Zollinger-Ellison syndrome
|
* generic available
|
5
|
Prevacid®, Prevacid® SoluTab™
(lansoprazole)*
Capsule
Orally disintegrating tablet (ODT)
|
- Short-term treatment of active duodenal ulcer in adults
- H. pylori eradication to reduce the risk of duodenal ulcer recurrence in adults
- Maintenance of healed duodenal ulcers in adults
- Short-term treatment of active benign gastric ulcer in adults
- Healing of non-steroidal anti-inflammatory drug (NSAID)-associated gastric ulcer
- Risk reduction of NSAID-associated gastric ulcer in adults
- Treatment of symptomatic GERD
- Treatment of erosive esophagitis
- Maintenance of healing of erosive esophagitis in adults
- Pathological hypersecretory conditions including Zollinger-Ellison syndrome in adults
|
* generic available
|
6
|
Prilosec®
(omeprazole)
Capsule*
Suspension packet
|
- Treatment of active duodenal ulcer in adults
- Eradication of Helicobacter pylori to reduce the risk of duodenal ulcer recurrence in adults
- Treatment of active benign gastric ulcer in adults
- Treatment of symptomatic GERD in patients 1 year of age and older
- Treatment of erosive esophagitis due to acid-mediated GERD in patients 1 month of age and older
- Maintenance of healing of erosive esophagitis due to acid-mediated GERD in patients 1 year of age and older
- Pathological hypersecretory conditions in adults
|
* generic available
|
7
|
Protonix®
(pantoprazole)
Tablet*
Suspension packet
|
- Short-term treatment of erosive esophagitis associated with GERD in patients 5 years of age and older
- Maintenance of healing of erosive esophagitis and reduction in relapse rates of daytime and nighttime heartburn symptoms in adult patients with GERD
- Pathological hypersecretory conditions including Zollinger-Ellison syndrome in adults
|
* generic available
|
8
|
Voquezna®
(vonoprazan)
Tablet
|
- Healing of erosive esophagitis
- Maintenance of healed erosive esophagitis
- Treatment of H. pylori infection
|
|
18
|
Zegerid®
(omeprazole/sodium bicarbonate)
Capsule*
Suspension packet
|
- Short-term treatment of active duodenal ulcer in adults
- Short-term treatment of active benign gastric ulcer in adults
- Treatment of heartburn and other symptoms associated with GERD in adults
- Treatment of erosive esophagitis due to acid-mediated GERD which has been diagnosed by endoscopy in adults
- Maintenance of healing of erosive esophagitis due to acid-mediated GERD in adults
- Reduction of risk of upper GI bleeding in critically ill adult patients (oral suspension only)
|
* 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, 16,18)
|
Aciphex is contraindicated in the following:
- Patients with known hypersensitivity to rabeprazole, substituted benzimidazoles, or to any component of the formulation
- Patients receiving rilpivirine-containing products
Dexilant is contraindicated in the following:
- Patients with known hypersensitivity to any component of the formulation
- Patients receiving rilpivirine-containing products
Esomeprazole Strontium is contraindicated in the following:
- Patients with known hypersensitivity to proton pump inhibitors (PPIs) (angioedema and anaphylaxis have occurred)
Konvomep is contraindicated in the following:
- Known hypersensitivity to any components of the formulation
- Patients receiving rilpivirine-containing products
Nexium is contraindicated in the following:
- Patients with known hypersensitivity to substituted benzimidazoles or any component of the formulation
- Patients receiving rilpivirine-containing products
Prevacid is contraindicated in the following:
- Patients with known severe hypersensitivity to any component of the formulation
- Patients receiving rilpivirine-containing products
Prilosec is contraindicated in the following:
- Patients with known hypersensitivity to substituted benzimidazoles or any component of the formulation
- Patients receiving rilpivirine-containing products
Protonix is contraindicated in the following:
- Patients with known hypersensitivity to substituted benzimidazoles or to any component of the formulation
- Patients receiving rilpivirine-containing products
Voquezna is contraindicated in the following:
- Known hypersensitivity to vonoprazan or any component of Voquezna
- Rilpivirine-containing products
Zegerid is contraindicated in the following:
- Patients with known hypersensitivity to substituted benzimidazoles or to any components of the formulation
- Patients receiving rilpivirine-containing products
|
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
|
18
|
Voquezna prescribing information. Phathom Pharmaceuticals, Inc. November 2023
|
POLICY AGENT SUMMARY STEP THERAPY
Target Brand Agent Name(s)
|
Target Generic Agent Name(s)
|
Strength
|
Targeted MSC
|
Available MSC
|
Final Age Limit
|
Preferred Status
|
|
|
esomeprazole strontium cap delayed release
|
49.3 MG
|
M ; N ; O
|
N
|
|
|
|
omeprazole cap delayed release
|
10 MG ; 20 MG ; 40 MG
|
M ; N ; O
|
Y
|
|
|
Aciphex
|
rabeprazole sodium ec tab
|
20 MG
|
M ; N ; O
|
O ; Y
|
|
|
Aciphex sprinkle
|
rabeprazole sodium capsule sprinkle dr
|
10 MG ; 5 MG
|
M ; N ; O
|
M ; N
|
|
|
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 MG ; 40 MG
|
M ; N ; O
|
O ; Y
|
|
|
Cvs lansoprazole ; Eq lansoprazole ; Eql lansoprazole ; Ft acid reducer ; Gnp lansoprazole ; Goodsense lansoprazole ; Hm lansoprazole ; Kls lansoprazole ; Prevacid ; Prevacid 24hr ; Qc lansoprazole ; Sm lansoprazole
|
lansoprazole cap delayed release
|
15 MG ; 30 MG
|
M ; N ; O
|
O ; Y
|
|
|
Cvs lansoprazole ; Goodsense lansoprazole ; Prevacid solutab
|
lansoprazole tab delayed release orally disintegrating
|
15 MG ; 30 MG
|
M ; N ; O
|
O ; Y
|
|
|
Cvs omeprazole/sodium bic ; Goodsense omeprazole/sodi ; Zegerid
|
omeprazole-sodium bicarbonate cap
|
20-1100 MG ; 40-1100 MG
|
M ; N ; O
|
O ; Y
|
|
|
Dexilant
|
dexlansoprazole cap delayed release
|
30 ; 30 MG ; 60 ; 60 MG
|
M ; N ; O
|
O ; Y
|
|
|
Konvomep
|
omeprazole-sodium bicarbonate for oral susp
|
2-84 MG/ML
|
M ; N ; O
|
N
|
|
|
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
|
M ; N ; O
|
N ; O ; Y
|
|
|
Nexium 24hr
|
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
|
|
|
Protonix
|
pantoprazole sodium ec tab
|
20 MG ; 40 MG
|
M ; N ; O
|
O ; Y
|
|
|
Protonix
|
pantoprazole sodium for delayed release susp packet
|
40 MG
|
M ; N ; O
|
O ; Y
|
|
|
Voquezna
|
vonoprazan fumarate tab
|
10 MG ; 20 MG
|
M ; N ; O
|
N
|
|
|
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 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 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 ; Ft acid reducer ; 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 ; Goodsense 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 ; Goodsense omeprazole/sodi ; 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 ; 30 MG ; 60 ; 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 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"
|
|
Voquezna
|
vonoprazan fumarate tab
|
10 MG
|
30
|
Tablets
|
30
|
DAYS
|
|
|
|
Voquezna
|
vonoprazan fumarate tab
|
20 MG
|
30
|
Tablets
|
30
|
DAYS
|
|
|
|
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"
|
|
ADDITIONAL QUANTITY LIMIT INFORMATION
Wildcard
|
Target Brand Agent Name(s)
|
Target Generic Agent Name(s)
|
Strength
|
Additional QL Information
|
Targeted NDCs When Exclusions Exist
|
Effective Date
|
Term Date
|
|
49270060006530
|
|
Omeprazole Cap Delayed Release 40 MG
|
40 MG
|
Smart QL: 1 capsule daily for 30 days; 2 capsules daily thereafter
|
|
|
|
49270070100620
|
Protonix
|
Pantoprazole Sodium EC Tab 40 MG (Base Equiv)
|
40 MG
|
Smart QL: 1 tablet daily for 30 days; 2 tablets daily thereafter
|
|
|
|
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 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 MG ; 40 MG
|
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; SourceRx
|
Cvs lansoprazole ; Eq lansoprazole ; Eql lansoprazole ; Ft acid reducer ; 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 ; Goodsense 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 ; Goodsense omeprazole/sodi ; 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 ; 30 MG ; 60 ; 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 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
|
Voquezna
|
vonoprazan fumarate tab
|
10 MG ; 20 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 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 MG ; 40 MG
|
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
|
Cvs lansoprazole ; Eq lansoprazole ; Eql lansoprazole ; Ft acid reducer ; 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 ; Goodsense 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 ; Goodsense omeprazole/sodi ; 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 ; 30 MG ; 60 ; 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 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
|
Voquezna
|
vonoprazan fumarate tab
|
20 MG
|
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
|
Voquezna
|
vonoprazan fumarate tab
|
10 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
|
|
TARGET AGENT(S)
|
PREREQUISITE AGENT(S)
|
Aciphex Sprinkle (rabeprazole) sprinkle capsule
Rabeprazole Sprinkle
Aciphex (rabeprazole) tablet*
Dexilant (dexlansoprazole) capsule*
Esomeprazole Strontium capsule
Konvomep (omeprazole/sodium bicarbonate) oral suspension
Nexium (esomeprazole magnesium) capsule*
Nexium (esomeprazole magnesium) suspension packet*
Prevacid (lansoprazole) capsule*
Prevacid Solutab (lansoprazole) orally disintegrating tablet (ODT)*
Prilosec (omeprazole) capsule*
Prilosec (omeprazole) suspension packet*
Protonix (pantoprazole) tablet*
Protonix (pantoprazole) suspension packet
Voquezna (vonoprazan) tablet
Zegerid (omeprazole/sodium bicarbonate) capsule*
Zegerid (omeprazole/sodium bicarbonate) suspension packet
|
Any generic proton pump inhibitor
|
* - generic available
Target Agent(s) will be approved when ONE of the following is met:
- The requested agent is eligible for continuation of therapy AND ONE of the following:
Agents Eligible for Continuation of Therapy
|
All target agents are eligible for continuation of therapy
|
-
- Information has been provided that indicates the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days OR
- The prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed OR
- The patient has a medication history of use in the past 90 days, intolerance, or hypersensitivity to ONE prescription strength prerequisite agent OR
- The patient has an FDA contraindication to ALL prescription strength prerequisite agents.
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:
- The requested quantity (dose) does NOT exceed the program quantity limit OR
- The requested quantity (dose) is greater than the program quantity limit AND ONE of the following:
- BOTH of the following:
- The requested agent does NOT have a maximum FDA labeled dose for the requested indication AND
- Information has been provided to support therapy with a higher dose for the requested indication OR
- BOTH of the following:
- The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND
- Information has been provided to support why the requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does NOT exceed the program quantity limit OR
- BOTH of the following:
- The requested quantity (dose) is greater than the maximum FDA labeled dose for the requested indication AND
- Information has been provided to support therapy with a higher dose for the requested indication
Length of Approval: up to 12 months
- Hypersecretory disease (i.e., Zollinger-Ellison Syndrome), Barrett's esophagitis, or esophageal stricture - approve 12 months
- Conventional therapy failure (failure of standard labeled dosing with the requested agent) - approve 12 months
- H pylori treatment - approve once
|
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 _ PPIs_STQL _ProgSum_ 04-01-2024
|