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Proton Pump Inhibitors (PPIs) Step Therapy with Quantity Limit Program Summary

Policy Number: PH-91068

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. 

The step therapy program is implemented with auto-grandfathering.

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
  • 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

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

Aciphex is contraindicated in the following:(1)

  • 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:(3)

  • Patients with known hypersensitivity to any component of the formulation
  • Patients receiving rilpivirine-containing products

Konvomep is contraindicated in the following:(16)

  • Known hypersensitivity to any components of the formulation
  • Patients receiving rilpivirine-containing products

Nexium is contraindicated in the following:(5)

  • Patients with known hypersensitivity to substituted benzimidazoles or any component of the formulation
  • Patients receiving rilpivirine-containing products

Prevacid is contraindicated in the following:(6)

  • Patients with known severe hypersensitivity to any component of the formulation
  • Patients receiving rilpivirine-containing products

Prilosec is contraindicated in the following:(7)

  • Patients with known hypersensitivity to substituted benzimidazoles or any component of the formulation
  • Patients receiving rilpivirine-containing products

Protonix is contraindicated in the following:(8)

  • 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:(18)

  • Known hypersensitivity to vonoprazan or any component of Voquezna
  • Rilpivirine-containing products

Zegerid is contraindicated in the following:(9)

  • 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. July 2023.

2

Aciphex Sprinkle prescribing information. Aytu Therapeutics, LLC. December 2020. Reference no longer used.

3

Dexilant prescribing information. Takeda Pharmaceuticals America, Inc. July 2023.

4

Esomeprazole strontium prescribing information. Amneal Pharmaceuticals LLC. March 2022. Reference no longer used.

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
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

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

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:

  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. 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 has a medication history of use in the past 90 days, intolerance, or hypersensitivity to ONE prescription strength prerequisite agent OR
  3. The patient has an FDA labeled 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:

  1. The requested quantity (dose) does NOT exceed the program quantity limit OR
  2. The patient has ONE of the following:
    1. A diagnosis of a hypersecretory disease (i.e., Zollinger-Ellison Syndrome, Barrett's esophagitis, or esophageal stricture) OR
    2. Inadequate response to FDA labeled dosing with the requested agent OR
    3. A diagnosis of H pylori OR
  3. The requested quantity (dose) exceeds 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. There is support for 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. There is support for 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) exceeds the maximum FDA labeled dose for the requested indication AND
      2. There is support for 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) - up to 12 months
  • Inadequate response to FDA labeled dosing - up to 12 months
  • H. pylori treatment - one time

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