Proton Pump Inhibitor (PPI) Step Therapy Program

Clinical literature¹ indicates that all PPIs are therapeutically equivalent at equal doses even though the cost of the drugs varies widely.

New Prescriptions After May 1, 2007

Drugs Affected

• Prevacid
• Nexium
• Aciphex
• Prilosec
• Protonix
• Zegerid

Program Details

Here are the steps to follow for PPIs to be a covered benefit for your patients:

• First prescribe either omeprazole or Prilosec OTC
• If you determine either of those drugs are not effective, you then must prescribe Prevacid
• If you determine Prevacid does not work, you may then prescribe Nexium, Aciphex, Prilosec, Protonix, or Zegerid and the drug will be covered

When following step therapy guidelines, no prior authorization (PA) is necessary. The prescription for the next level of PPI will automatically approve if there is prior history in the claims system of the lower level PPI.

If you believe it is medically appropriate for you patient to “skip” steps, you will need to submit a prior authorization request and receive approval for the drug to be covered.

Patients Who Currently Have A Prior Authorization (PA)

If a patient currently has a prior authorization in place for Nexium, Aciphex, Prilosec, Protonix, or Zegerid, the patient can stay on the current PPI prescription until the PA expires. When the PA expires, here are the steps to follow for PPIs to be a covered benefit for your patients:

• First prescribe either omeprazole or Prilosec OTC
• If you determine either of those drugs are not effective, you then must prescribe Prevacid
• If you determine Prevacid does not work, you may then prescribe Nexium, Aciphex, Prilosec, Protonix, or Zegerid and the drug will be covered

When following step therapy guidelines, no prior authorization (PA) is necessary. The prescription for the next level of PPI will automatically approve if there is prior history in the claims system of the lower level PPI.

If you believe it is medically appropriate for you patient to “skip” steps, you will need to submit a prior authorization request and receive approval for the drug to be covered.

 Patients Currently In The 90-Day Standard Allowance

Effective May 1, 2007, the 90-day standard allowance is no longer in effect. If a patient has been taking Nexium, Aciphex, Prilosec, Protonix, or Zegerid but does not have a PA in place before May 1, 2007, here are the steps to follow for PPIs to be a covered benefit:

• First prescribe either omeprazole or Prilosec OTC
• If you determine either of those drugs are not effective, you then must prescribe Prevacid
• If you determine Prevacid does not work, you may then prescribe Nexium, Aciphex, Prilosec, Protonix, or Zegerid and the drug will be covered

When following step therapy guidelines, no prior authorization (PA) is necessary. The prescription for the next level of PPI will automatically approve if there is prior history in the claims system of the lower level PPI.

If you believe it is medically appropriate for you patient to “skip” steps, you will need to submit a prior authorization request and receive approval for the drug to be covered.

 ¹McDonagh MS, Carson S. Drug Class Review on Proton Pump Inhibitors. 2006. http://www.ohsu.edu/drugeffectiveness/reports/final.cfm.

Ip S, Bonis P, Tatsioni A, Raman G, Chew P, Kupelnick B, Fu L, DeVine D, Lau J. Comparative Effectiveness of Management Strategies for Gastroesophagel Reflux Disease. Evidence Report/Technology Assessment No. 1. (Prepared by Tufts-New England Medical Center Evidence-based Practice Center under Contract No. 290-02-022.) Rockville, MD: Agency for www.effectivehealthcare.ahrq.gov/reports/final.cfm.

DeVault K, Castell D, Updated Guidelines for the Diagnosis and Treatment of Gastroesophageal Reflux Disease. Am J Gastroenterol 2005;100:190-200.

Liker H, Hungin P, Wiklund I. Managing Gastroesophageal Reflux Disease in Primary Care: The Patient Perspective. J Am Board Fam Pract 2005;18:393-400.

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