OHP MEDICATION GUIDELINE DCIPA, LLC Proton Pump Inhibitors Approved by: Quality Improvement & Utilization Committee Last Date Approved: 6/12
1. Coverage is limited to treatment of above the line diagnoses. 2. Use of generic medications where available will always be preferred to high cost generic or
3. Certain medications are not covered when similar medications are available at lower cost.
Guidelines:
Omeprazole-Prilosec® Pantoprazole-Protonix® Lanzoprazole-Prevacid®
Dexlansoprazole-Dexilant® Esomeprazole-Nexium® omeprazole/sodium bicarbonate-Zegerid® rabeprazole-Aciphex®
1. No prior authorization is required for omeprazole 20mg and 40mg capsules and pantoprazole
20mg and 40 mg tablets, up to 60 per 30 day supply.
2. Prior authorization is required for all other PPIs with chart notes that document an above the
line condition, and failure or intolerance to both omeprazole and pantoprazole at maximum doses. References:
1. Aciphex prescribing information. Eisai, Inc. June 2008. 2. Nexium prescribing information. AstraZeneca LP. February 2008. 3. Prevacid prescribing information. TAP Pharmaceuticals Inc. July 2007. 4. Prilosec prescribing information. AstraZeneca LP. March 2008. 5. Protonix prescribing information. Wyeth Pharmaceuticals, Inc. December 2007. 6. Zegerid prescribing information. Santarus, Inc. January 2008.
Originated: _________________________ Reviewed: 06/12/02, 10/30/03, 06/07/06, 4/20/2011
7. Stedman CAM, Barclay ML. Review article: comparison of pharmacokinetics, acid
suppression, and efficacy of proton pump inhibitors. Aliment Pharmacol Ther 2000;14:963-978.
8. Goodman F. Abbreviated drug class review: Proton pump inhibitors. Pharmacy Benefits
Management Strategic Healthcare Group. Medical Advisory Panel. July 2001. Available at: http://www.vapbm.org/reviews/ppiabbreviatedreview.pdf. Accessed September, 2005.
9. Edwards SJ, Lind T, Lundell L. Systematic review of proton pump inhibitors for the
acute treatment of reflux oesophagitis. Aliment Pharmacol Ther 2001;15:1729-1736.
10. FDA Center for Drug Evaluation and Research, New Drug Application (NDA) Nexium
(esomeprazole magnesium) delayed release capsules. AstraZeneca LP. Application Number 21-153 & 21-154. Approval Date February 20, 2001. Available at: http://www.fda.gov/cder/foi/nda/2001/21154_Nexium.htm. Accessed June 28, 2006.
11. Castell DO, Kahrilas PJ, Richter JE, et al. Esomeprazole (40 mg) compared with
lansoprazole (30 mg) in the treatment of erosive esophagitis. Am J Gastroenterol 2002;97:575-583.
12. Thjodleifsson B, Becker JA, Dekkers C, et al. Rabeprazole versus omeprazole in
preventing relapse of erosive or ulcerative gastroesophagitis reflux disease: a double-blind, multicenter, European trial. The European Rabeprazole Study Group. Digestive Diseases & Sciences 2000;45(5):845-853.
13. Thjodleifsson B, Rindi G, Fiocca R, et al. A randomized, double-blind trial of the
efficacy and safety of 10 or 20 mg rabeprazole compared with 20 mg omeprazole in the maintenance of gastro-oesophageal reflux disease over 5 years. Aliment Pharmacol Ther 2003;17:343-351.
14. Lauritsen K, Deviere J, Bigard MA, et al. Esomeprazole 20 mg and lansoprazole 15 mg
in maintaining healed reflux oesophagitis: Metropole study results. Aliment Pharmacol Ther 2003;17:333-341.
15. DeVault KR, Castell DO. Updated guidelines for the diagnosis and treatment of
gastroesophageal reflux disease. Am J Gastroenterol. 2005;100:190-200.
16. Chang FY, Chiang CY, Tam TN, Ng WW, Lee SD. Comparison of lansoprazole and
omeprazole in the short-term management of duodenal ulcers in Taiwan. J Gastroenterol Hepatol 1995;10(5):595-601.
17. Eckstrom P, Carling L, Unge P, Anker-Hanse O, Sjostedt S, Sellstrom H. Lansoprazole
versus omeprazole in active duodenal ulcer. A double-blind, randomized, comparative study. Scand J Gastroenterol 1995;30(3):210-215.
18. HCSC_CS_S_PPI_ST_AR0908_r1010-2.doc Page 7 of 8 Copyright 19. Weaver K. Proton pump inhibitors. Oregon Health Resources Commission. April 2004. 20. The American Gastroenterological Association Institute Medical Position Panel.
American Gastroenterological Association Technical Review on the Management of Gastroesophageal Reflux.
SUPPORTING DOCUMENTATION: The medication request does not meet the guidelines of the Douglas County IPA. According to OAR 410-141-0070 and OAR 410-12-1200, certain medications are not covered when similar medications are available at a lower cost.
Christine M. Seals, MD, Medical Director of DCIPA, LLC Originated: _________________________ Reviewed: 06/12/02, 10/30/03, 06/07/06, 4/20/2011
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OHP MEDICATION GUIDELINE