Subject: PPI Limit Policy 168-H 04-2024
| PROTON PUMP INHIBITORS |
|
ACIPHEX
(rabeprazole)
|
|
ACIPHEX SPRINKLES
(rabeprazole)
|
|
DEXILANT
(dexlansoprazole)
|
|
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)
|
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 of therapy 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:
- Aciphex [package insert]. Wixom, MI: Waylis Therapeutics LLC; July 2023.
- Aciphex Sprinkles [package insert]. Rockville, MD: Atyu Therapeutics, LLC/Cerecor, Inc.; December 2020.
- Dexilant [package insert]. Lexington, MA: Takeda Pharmaceuticals America, Inc.; July 2023.
- Konvomep [package insert]. Woburn, MA: Azurity Pharmaceuticals, Inc.; August 2023.
- Nexium [package insert]. Wilmington, DE: AstraZeneca Pharmaceuticals LP; July 2023.
- Omeprazole Capsules [package insert]. East Windsor, NJ: Aurobindo Pharma USA, Inc.; April 2023.
- Prevacid, Prevacid SoluTab [package insert]. Lexington, MA: Takeda Pharmaceuticals America, Inc.; August 2023.
- Prilosec Granules [package insert]. Zug, Switzerland: Covis Pharma; March 2022.
- Protonix [package insert]. Philadelphia, PA: Wyeth Pharmaceuticals LLC; June 2023.
- Zegerid [package insert]. Bridgewater, NJ: Salix Pharmaceuticals; July 2023.
- Lexicomp Online, AHFS DI (Adult and Pediatric) Online. Waltham, MA: UpToDate, Inc.; 2024. https://online.lexi.com. Accessed March 06, 2024.
- Micromedex® (electronic version). Merative, Ann Arbor, Michigan, USA. Available at: https://www.micromedexsolutions.com/ (cited: 03/06/2024).
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.
August 11, 2024
