MHCP Enrolled Providers – Pharmacies
Fee-for-Service PA Criteria Sheet – Proton Pump Inhibitors (PPIs)
(October 2015)
Drug
Therapeutic Area
Proton Pump Inhibitors (PPIs)
Gastrointestinal
Preferred
omeprazole - generic
pantoprazole - generic
Nexium packet for suspension
Non preferred
Capsule formulation
Aciphex(rabeprazole)
Dexilant (dexlansoprazole)
Nexium (esomeprazole)
Prilosec brand (omeprazole)
Prevacid (lansoprazole)
Protonix (pantoprazole)
lansoprazole – generic
omeprazole/bicarbonate generic
Zegerid
(legend)(omeprazole/bicarbonate)
Prilosec OTC excluded from coverage.
Prevacid OTC is excluded from coverage.
Zegerid OTC is excluded from coverage
Other dosage forms
Prevacid Solutab
Lansoprazole solutab
Prilosec packet for
suspension
CRITERIA
Non-preferred drugs- capsule formulation (Excludes Nexium)
 The recipient has failed trials of omeprazole and pantoprazole due to lack of efficacy or presence of significant sideeffects when dosed at the same frequency (e.g., QD, BID) as the requested drug. Trials should be 2 weeks in duration.
<br>
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
<br>
MHCP Provider Call Center 651-431-2700 or 800-366-5411