Coverage Guidelines: Proton Pump Inhibitors

Coverage Guidelines: Proton Pump Inhibitors _____________________________________________________________________________________________________________________

Policy Network Health covers the preferred generic proton pump inhibitors (PPIs) omeprazole (Prilosec over-the-counter [OTC] and prescription Prilosec), pantoprazole (prescription Protonix tablets), and lansoprazole (Prevacid OTC) for Network Health Together®, Network Health Forward®, and Network Health Extend members without prior authorization. Network Health covers the non-preferred PPIs omeprazole (Prilosec Suspension, Zegerid, and Zegerid Suspension), pantoprazole (Protonix Suspension), lansoprazole (prescription Prevacid capsules and Prevacid SoluTabs), dexlansoprazole (Dexilant), Esomeprazole (Nexium and Nexium Suspension), and rabeprazole (Aciphex) for Network Health Together, Network Health Forward, and Network Health Extend members with prior authorization. When generic drugs are available, Network Health will not cover the brand-name drug without prior authorization.

Covered conditions Network Health covers the following non-preferred PPIs with prior authorization when the member meets the criteria listed for each drug:

Lansoprazole (prescription Prevacid capsules)  Member has tried and failed treatment with, or a provider has documented clinical inappropriateness of treatment with, omeprazole (prescription or OTC) and lansoprazole (OTC) Dexlansoprazole (Dexilant) Esomeprazole (Nexium) Omeprazole/sodium bicarbonate (Zegerid) Rabeprazole (Aciphex)  Member has tried and failed treatment with, or a provider has documented clinical inappropriateness of treatment with, omeprazole (prescription or OTC), lansoprazole (prescription or OTC), and pantoprazole Lansoprazole rapid dissolving tablets (Prevacid SoluTabs) Omeprazole granules (Prilosec Suspension) Omeprazole/sodium bicarbonate suspension (Zegerid Suspension) Pantoprazole granules (Protonix Suspension)  Member is 13 years of age or younger, or  Member is over the age of 13 and a provider has documented that the member is unable to swallow oral capsules or tablets ____________________________________________________________________________________________________________________ These guidelines apply to Network Health Together, Network Health Forward, and Network Health Extend plans. Coverage is based on member benefits and eligibility; medical necessity review, where applicable; and the Network Health provider agreement. Adherence to these guidelines by a provider does not guarantee coverage. Network Health reserves the right to amend these guidelines at its discretion.

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Network Health Coverage Guidelines – Proton Pump Inhibitors

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Esomeprazole granules (Nexium Suspension)  Member is 13 years of age or younger, or member is over the age of 13 and a provider has documented that the member is unable to swallow oral capsules or tablets, and  Member has tried and failed treatment with at least two of the following: omeprazole granules, omeprazole/sodium bicarbonate suspension, lansoprazole rapid dissolving tablets, or pantoprazole granules Please note: Network Health will approve the above non-preferred PPIs for lifetime use for members, according to the conditions described in the covered conditions section.

Guidelines references Kahrilas, P.J., Shaheen, N.J., Vaezi, M.F., Hiltz, S.W., Black, E., et al. (2008). American Gastroenterological Association Medical Position Statement on the Management of Gastroesophageal Reflux Disease. Gastroenterology. 135, 1383 – 1391. Talley, N.J., Vakil, N., and the Practice Parameters Committee of the American College of Gastroenterology (2005). Guidelines for the Management of Dyspepsia. American Journal of Gastroenterology. 100, 2324 – 2337.

____________________________________________________________________________________________________________________ These guidelines apply to Network Health Together, Network Health Forward, and Network Health Extend plans. Coverage is based on member benefits and eligibility; medical necessity review, where applicable; and the Network Health provider agreement. Adherence to these guidelines by a provider does not guarantee coverage. Network Health reserves the right to amend these guidelines at its discretion.

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Network Health Coverage Guidelines – Proton Pump Inhibitors

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