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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 |
10-01-2024 |
|
FDA LABELED INDICATIONS AND DOSAGE
Agent(s) |
FDA Indication(s) |
Notes |
Ref# |
Aciphex® Sprinkle™, Rabeprazole Sprinkle Capsule |
|
|
2 |
Aciphex® (rabeprazole)* Tablet |
|
* generic available |
1 |
Dexilant® (dexlansoprazole)* Capsule |
|
* generic available |
3 |
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 |
Voquezna® (vonoprazan) Tablet |
|
|
18 |
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 |
Aciphex is contraindicated in the following:(1)
Dexilant is contraindicated in the following:(3)
Konvomep is contraindicated in the following:(16)
Nexium is contraindicated in the following:(5)
Prevacid is contraindicated in the following:(6)
Prilosec is contraindicated in the following:(7)
Protonix is contraindicated in the following:(8)
Voquezna is contraindicated in the following:(18)
Zegerid is contraindicated in the following:(9)
|
REFERENCES
Number |
Reference |
1 |
Aciphex prescribing information. Woodward Pharm Services LLC. July 2023. |
2 |
|
3 |
Dexilant prescribing information. Takeda Pharmaceuticals America, Inc. July 2023. |
4 |
E |
5 |
Nexium prescribing information. AstraZeneca Pharmaceuticals LP. July 2023. |
6 |
Prevacid prescribing information. Takeda Pharmaceuticals America, Inc. August 2023. |
7 |
Prilosec delayed-release suspension prescribing information. Covis Pharma. July 2023. |
8 |
Protonix prescribing information. Wyeth Pharmaceuticals LLC. July 2023. |
9 |
Zegerid prescribing information. Santarus Inc. July 2023. |
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 |
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 |
|
||||||
|
omeprazole cap delayed release |
10 MG ; 20 MG ; 40 MG |
M ; N ; O |
Y |
|
|
|
rabeprazole sodium capsule sprinkle dr |
10 MG |
M ; N ; O |
N |
|
|
Aciphex |
rabeprazole sodium ec tab |
20 ; 20 MG |
M ; N ; O |
O ; Y |
|
|
Cvs esomeprazole magnesiu ; Eq esomeprazole magnesium ; Ft acid reducer ; 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 MG ; 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 |
|
|||||||||
|
omeprazole cap delayed release |
10 MG ; 20 MG ; 40 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
|
rabeprazole sodium capsule sprinkle dr |
10 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
|
vonoprazan fumarate tab |
|
30 |
Tablets |
30 |
DAYS |
|
|
|
|
vonoprazan fumarate tab |
|
30 |
Tablets |
30 |
DAYS |
|
|
|
Aciphex |
rabeprazole sodium ec tab |
20 ; 20 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Cvs esomeprazole magnesiu ; Eq esomeprazole magnesium ; Ft acid reducer ; 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 |
60 |
Capsules |
30 |
DAYS |
|
|
|
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 |
60 |
Capsules |
30 |
DAYS |
|
|
|
Cvs lansoprazole ; Goodsense lansoprazole ; Prevacid solutab |
lansoprazole tab delayed release orally disintegrating |
15 MG ; 30 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Cvs omeprazole/sodium bic ; Goodsense omeprazole/sodi ; Zegerid |
omeprazole-sodium bicarbonate cap |
20-1100 MG ; 40-1100 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
Dexilant |
dexlansoprazole cap delayed release |
30 MG ; 60 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
Konvomep |
omeprazole-sodium bicarbonate for oral susp |
2-84 MG/ML |
600 |
mLs |
30 |
DAYS |
|
|
|
Nexium |
Esomeprazole Magnesium For Delayed Release Susp Pack 2.5 MG |
2.5 MG |
30 |
Packets |
30 |
DAYS |
|
|
|
Nexium |
Esomeprazole Magnesium For Delayed Release Susp Packet 10 MG |
10 MG |
60 |
Packets |
30 |
DAYS |
|
|
|
Nexium |
Esomeprazole Magnesium For Delayed Release Susp Packet 20 MG |
20 MG |
60 |
Packets |
30 |
DAYS |
|
|
|
Nexium |
Esomeprazole Magnesium For Delayed Release Susp Packet 40 MG |
40 MG |
60 |
Packets |
30 |
DAYS |
|
|
|
Nexium |
Esomeprazole Magnesium For Delayed Release Susp Packet 5 MG |
5 MG |
30 |
Packets |
30 |
DAYS |
|
|
|
Nexium 24hr |
esomeprazole magnesium tab delayed release |
20 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Prilosec |
Omeprazole Magnesium For Delayed Release Susp Packet 10 MG |
10 MG |
30 |
Packets |
30 |
DAYS |
|
|
|
Prilosec |
Omeprazole Magnesium For Delayed Release Susp Packet 2.5 MG |
2.5 MG |
60 |
Packets |
30 |
DAYS |
|
|
|
Protonix |
pantoprazole sodium ec tab |
20 MG ; 40 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Protonix |
pantoprazole sodium for delayed release susp packet |
40 MG |
60 |
Packets |
30 |
DAYS |
|
|
|
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 |
60 |
Packets |
30 |
DAYS |
|
|
|
CLIENT SUMMARY – STEP THERAPY
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
|
omeprazole cap delayed release |
10 MG ; 20 MG ; 40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; SourceRx |
|
rabeprazole sodium capsule sprinkle dr |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; SourceRx |
Aciphex |
rabeprazole sodium ec tab |
20 ; 20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; SourceRx |
Cvs esomeprazole magnesiu ; Eq esomeprazole magnesium ; Ft acid reducer ; 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 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 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 |
|
omeprazole cap delayed release |
10 MG ; 20 MG ; 40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
rabeprazole sodium capsule sprinkle dr |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
vonoprazan fumarate tab |
|
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
vonoprazan fumarate tab |
|
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Aciphex |
rabeprazole sodium ec tab |
20 ; 20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Cvs esomeprazole magnesiu ; Eq esomeprazole magnesium ; Ft acid reducer ; 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 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 2.5 MG |
2.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Nexium |
Esomeprazole Magnesium For Delayed Release Susp Packet 10 MG |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Nexium |
Esomeprazole Magnesium For Delayed Release Susp Packet 20 MG |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Nexium |
Esomeprazole Magnesium For Delayed Release Susp Packet 40 MG |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Nexium |
Esomeprazole Magnesium For Delayed Release Susp Packet 5 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 for delayed release susp packet |
40 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 |
Voquezna |
vonoprazan fumarate tab |
20 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 _ PPIs_STQL _ProgSum_ 10-01-2024