Subject: PPI Limit Policy 168-H 02-2022 v2

Drug

PROTON PUMP INHIBITORS

ACIPHEX  (rabeprazole)

ACIPHEX SPRINKLES  (rabeprazole)

DEXILANT  (dexlansoprazole)

esomeprazole strontium

KONVOMEP  (omeprazole/sodium bicarbonate)

NEXIUM  (esomeprazole)

PREVACID  (lansoprazole)

PRILOSEC  (omeprazole)

PROTONIX  (pantoprazole)

ZEGERID  (omeprazole/sodium bicarbonate)

Policy:

FDA APPROVED INDICATIONS

Indication	AcipHex (rabeprazole)	AcipHex Sprinkles (rabeprazole)	Dexilant (dexlansoprazole)	Konvomep (omeprazole/ sodium bicarbonate)	Nexium (esomeprazole)  Esomeprazole   strontium	Prevacid (lansoprazole)	Prilosec (omeprazole)	Protonix (pantoprazole)	Zegerid (omeprazole/ sodium bicarbonate)
Short-term treatment of active duodenal ulcer	√					√	√		√
Helicobacter pylori eradication to reduce the risk of ulcer recurrence*	√				√	√	√
Maintenance of healing of duodenal ulcers						√
Short-term treatment of gastric ulcer				√		√	√		√
Short-term treatment of symptoms associated with GERD	√	√	√		√	√	√	√	√
Short-term treatment of erosive esophagitis / GERD	√		√		√	√	√	√	√
Maintenance healing of erosive esophagitis	√		√		√	√	√	√	√
Pathological hypersecretory conditions	√				√	√	√	√
Short-term treatment of NSAID-associated gastric ulcer						√
Risk reduction of NSAID-associated gastric ulcer					√	√
Risk reduction of upper GI bleeding in critically ill patients				√					√ Suspension

*The PPI is used in conjunction with antibiotics. 

LIMIT CRITERIA Limits should accumulate across all drugs and strengths (accumulation does not apply if limit is coded for daily dose).
Drug	Limit*
All products in the PPI drug class, all strengths	90 units total per 365 days
*If the patient requires more than 90 units of therapy per 365 days, then please refer to the PPI Post Limit PA

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. AcipHex [package insert]. Woodcliff Lake, NJ: Eisai, Inc.; October 2021.
2. AcipHex Sprinkles [package insert]. Rockville, MD: Atyu Therapeutics, LLC/Cerecor, Inc.; December 2020.
3. Dexilant [package insert]. Lexington, MA: Takeda Pharmaceuticals America, Inc.; November 2020.
4. Esomeprazole Strontium [package insert]. Glasgow, KY: Amneal Pharmaceuticals LLC; January 2021.
5. Konvomep [package insert]. Woburn, MA: Azurity Pharmaceuticals, Inc.; August 2022.
6. Nexium [package insert]. Wilmington, DE: AstraZeneca Pharmaceuticals LP; August 2021.
7. Omeprazole Capsules [package insert]. Weston, FL: Apotex Corp.; November 2020.
8. Prevacid, Prevacid SoluTab [package insert]. Lexington, MA: Takeda Pharmaceuticals America, Inc.; November 2020.
9. Prilosec Granules [package insert]. Zug, Switzerland: Covis Pharma; December 2021.
10. Protonix [package insert]. Philadelphia, PA: Wyeth Pharmaceuticals LLC; November 2020.
11. Zegerid [package insert]. Bridgewater, NJ Salix Pharmaceuticals, Inc; November 2020.
12. Lexicomp Online, AHFS DI (Adult and Pediatric) Online, Hudson, Ohio: UpToDate, Inc.; 2021; Accessed January 6, 2022.
13. Micromedex (electronic version). IBM Watson Health, Greenwood Village, Colorado, USA. Available at: https://www.micromedexsolutions.com. Accessed January 6, 2022.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

October 16, 2022