Proton Pump Inhibitor (PPI) Step Therapy Program

PPIs are drugs used to treat various stomach and digestive problems, including heartburn. Clinical literature 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

This is how the step therapy program works for new PPI prescriptions.

Drugs Affected

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

Program Details

For PPIs to be a covered benefit, you must follow these steps:

• You must first try either omeprazole or Prilosec OTC
• If your doctor determines either of those drugs are not effective, you must then try Prevacid
• If your doctor determines Prevacid does not work, you may then have Nexium, Aciphex, Prilosec, Protonix, or Zegerid as a covered benefit

If your doctor wants you to “skip” steps, your doctor will need to submit a prior authorization request and receive approval for the drug to be covered.

Members Who Currently Have A Prior Authorization (PA)

If you currently have a prior authorization in place for Nexium, Aciphex, Prilosec, Protonix, or Zegerid, you can stay on your current PPI prescription until your PA expires. When your PA expires, you will need to follow these steps for your PPI to be a covered benefit:

• You must first try either omeprazole or Prilosec OTC
• If your doctor determines either of those drugs are not effective, you must then try Prevacid
• If your doctor determines Prevacid does not work, you may then have Nexium, Aciphex, Prilosec, Protonix, or Zegerid as a covered benefit

You can also discuss with your doctor about moving now to either omeprazole or Prilosec OTC as this change may lower your out-of-pocket costs at the pharmacy.

You will need a new prescription to make the change; your pharmacist cannot make the change for you without doctor approval.

If your doctor wants you to “skip” steps, your doctor will need to submit a prior authorization request and receive approval for the drug to be covered.

Members Currently On A PPI Who Do Not Have A PA in Place

If you currently are taking Nexium, Aciphex, Prilosec, Protonix, or Zegerid but do not have a PA in place, at your next refill, you will need to follow these steps for your PPI to be a covered benefit:

• You must first try either omeprazole or Prilosec OTC
• If your doctor determines either of those drugs are not effective, you must then try Prevacid
• If your doctor determines Prevacid does not work, you may then have Nexium, Aciphex, Prilosec, Protonix, or Zegerid as a covered benefit

You will need a new prescription to make the change; your pharmacist cannot make the change for you without doctor approval.

If your doctor wants you to “skip” steps, your doctor will need to submit a prior authorization request and receive approval for the drug to be covered.

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