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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 

7/1/2023

FDA APPROVED INDICATIONS AND DOSAGE

Agent(s)

FDA Indication(s)

Notes

Ref#

Aciphex®  Sprinkle™, Rabeprazole Sprinkle

Capsule

Treatment of GERD in pediatric patients 1 to 11 years of age for up to 12 weeks

branded generic available

 

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

branded generic available

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 disintigrating 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

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)

 

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 individualcases.(10-13)

Safety(1-9)

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 patients with known hypersensitivity to proton pump inhibitors (PPIs) (angioedema and anaphylaxis have occurred).

 

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

 

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. Eisai Inc. November 2020.

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, Gerson LB, Vela MF, et al. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol.  2013;108:308-328.

11

Drugs for peptic ulcer disease and GERD. Medical Letter Treatment Guidelines. 2014;12(140):25-30. North Am Soc for Pediatric Gastroenterology, Hepatology, & Nutrition/European Society for Pediatric Gastroenterology, Hepatology, & Nutrition Guideline H.Pylori 2011. JPGN. 2011;53:230-243.

12

Management of patients with ulcer bleeding. American Journal of Gastroenterology. 2012 Mar;107(3):345-60.

13

American Gastroenterological Association medical position statement on the management of Barrett’s esophagus. Gastroenterology. 2011 Mar;140(3):1084-91.

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.

 

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

M ; N

OMEPRAZOLE*omeprazole cap delayed release

10 MG ; 20 MG ; 40 MG

M ; N ; O

O ; Y

ACIPHEX*rabeprazole sodium ec tab  ; RABEPRAZOLE*rabeprazole sodium ec tab

20  ; 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 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

N ; 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 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 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  ; 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 ; 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 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 ; 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

Aciphex

rabeprazole sodium ec tab

20  ; 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 ; 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 ; 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 ; 2.5 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

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

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  ; 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 ; 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 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

Target Agent(s) will be approved when ONE of the following is met:

 

  1. 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
    1. 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
    2. 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
  2. The patient’s medication history includes use of a preferred prescription strength generic PPI within the past 90 days OR
  3. The patient has an intolerance or hypersensitivity to a preferred prescription strength generic PPI OR
  4. The patient has an FDA labeled contraindication to ALL preferred prescription strength generic PPIs

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:

  1. The requested quantity (dose) does NOT exceed the program quantity limit OR
  2. The requested quantity (dose) is greater than the program quantity limit AND ONE of the following:
    1. BOTH of the following:
      1. The requested agent does not have a maximum FDA labeled dose for the requested indication AND
      2. Information has been provided to support therapy with a higher dose for the requested indication OR
    2. BOTH of the following:
      1. The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND
      2. 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
    3. BOTH of the following:
      1. The requested quantity (dose) is greater than the maximum FDA labeled dose for the requested indication AND
      2. Information has been provided to support therapy with a higher dose for the requested indication

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) Step Therapy with Quantity Limit _ProgSum_ 7/1/2023