PROTON PUMP INHIBIOTORS (PPI) STEP THERAPY
The PPI step therapy program supports the coverage of a prescription PPI
after the use of:
1. a histamine- (2) receptor antagonist (H2Ra or H-2 blocker) taken in a therapeutic strength (ranitidine dosed at 150mg qd or bid, or 300mg qd or bid for a period of 3-4 weeks; or cimetidine dosed as 800mg @ bedtime, 300mg qid, or 400mg bid for 3-4 weeks) for uncomplicated gastroesophageal reflux disease (GERD), gastric ulcer and duodenal ulcer.
And
2. the use of an over-the-counter (OTC) prilosec in a therapeutic dosage (20mg qd or 40mg qd) for a period of 3-4 weeks
The objective of the program is to allow coverage for PPI products that
are on the formulary for participants (patients) who have previously tried a H2Ra product and an OTC prilosec. Utilization of a
H2Ra product is required and utilization of the OTC prilosec
is required before a prescription for a PPI product will be covered.
When the participant attempts to process a prescription for a legend,
formulary PPI, the computer will search for a history of an H2Ra and for a
history of PRILOSEC or omeprazole. If the patient has had a prescription for an
H2Ra, the electronic messaging will direct the patient to use of OTC prilosec. If the
step therapy rules have been met, a prior authorization will be provided by
MAHP for processing the prescription, formulary PPI online. If the step therapy rules are not met the
pharmacy will be directed, via electronic messaging from the PBM, Plan Limitations Exceeded,
Should the practitioner choose to use the legend PPI without meeting the step criteria, and the participant wants the prescription given special consideration for payment within their prescription drug benefit, the practitioner must contact Health Care Services at MAHP and provide additional medical/clinical information for review. If the medical/clinical information meets criteria for a medical exception to this step therapy, a prior authorization may be granted, allowing payment under the prescription drug benefit. If the medical/clinical information is determined not to meet the criteria for granting a prior authorization for payment after review by MAHP Medical Director, the participant may elect to pay privately for the prescription.
*One H2 and Prilosec OTC failure before second line, may change within second line if valid fill in last four months.
|
|
FIRST-LINE
DRUGS |
SECOND-LINE
DRUGS |
|
MEDICATIONS |
Histamine-2 Receptor
Antagonists: Cimetidine
(TAGAMET) Ranitidine
(ZANTAC) and Proton Pump Inhibitor OTC: Omeprazole (PRILOSEC OTC) |
Proton Pump
Inhibitors: Lansoprazole(PREVACID) Pantoprazole(PROTONIX) |
|
CRITERIA FOR USE |
Driven
by formulary status of drug, formulary is closed and MAC policies **Processing
of brand name first-line drug will cause ancillary charges to e charged to
the participant. |
·
Participant has one RX in claims history from the
first-line drug category within 130 days prior to the prescription date of a
legend PPI
OR ·
Has a prescription claims history of PPI within
130 days of the prescription date,
.OR ·
PPI prescription is meeting the criteria for a
medical exception |
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