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    Proton Pump Inhibitors

    Drug - Proton Pump Inhibitors (PPIs)

    October 2015

    Therapeutic area - Gastrointestinal

    Preferred
    omeprazole - generic
    pantoprazole - generic
    Nexium packet for suspension

    Nonpreferred
    Capsule formulation
    Aciphex(rabeprazole)
    Dexilant (dexlansoprazole)
    Nexium (esomeprazole)
    Prilosec brand (omeprazole)
    Prevacid (lansoprazole)
    Protonix (pantoprazole)
    lansoprazole – generic
    omeprazole/bicarbonate generic
    Zegerid (legend)(omeprazole/bicarbonate)

    Other dosage forms
    Prevacid Solutab
    Lansoprazole solutab
    Prilosec packet for suspension

    Prilosec OTC excluded from coverage.
    Prevacid OTC is excluded from coverage.
    Zegerid OTC is excluded from coverage

    Criteria

    Nonpreferred drugs- capsule formulation (Excludes Nexium)

    • The recipient has failed trials of omeprazole and pantoprazole due to lack of efficacy or presence of significant side-effects when dosed at the same frequency (e.g., QD, BID) as the requested drug. Trials should be 2 weeks in duration

    Other dosage forms including Prevacid Solutab, lansoprazole solutab, or Prilosec packet

    • Patient or patient caregiver cannot open a capsule of a preferred agent and sprinkle the contents into 1/4 cup of apple, tomato or orange juice, or onto a tablespoon of applesauce, Ensure® pudding, cottage cheese, yogurt, or strained pears without crushing or chewing the capsules or the granules OR
    • Patient is being administered the proton pump inhibitor by G tube and has failed a trial of esomeprazole suspension

    Questions?

    MHCP Provider Call Center 651-431-2700 or 800-366-5411

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