P r e a u t h o r i z at i o n P r o g r a m
managing the treatment of gastrointestinal conditionsProton PumP inhiBitorS
Preauthorization programs target higher cost drugs that have lower cost alternatives. Typical y, these less expensive drugs provide the same or greater level of safety and effectiveness to treat a particular condition as their more costly counterparts. Your coverage includes a preauthorization program for proton pump inhibitors (PPIs).
What are proton pump inhibitors?
Proton pump inhibitors, also known as PPIs, are used
to help reduce stomach acid and provide relief from the
symptoms of heartburn, ulcers and gastroesophageal
reflux disease (GERD).
The generic PPI medications omeprazole and pantoprazole, and the brand name drug Aciphex® are listed on the Blue Cross and Blue Shield of Nebraska formulary. Non-formulary drugs in this class include brand name Kapidex™, Nexium®, Prevacid®, Prilosec®, Protonix® and Zegerid®.
Why are PPIs included in the
Clinical studies show that for most patients, all
PPIs, regardless of their price, offer similar safety
and effectiveness. The PPI drug class is one of
the most costly for your employer and health plan.
The medications listed on the formulary represent
the lowest cost options. By using a lower cost
formulary PPI, you play a key role in controlling
the cost of your prescription drug benefit.
How does the program work?
The preauthorization program requires attempted
use of all three formulary PPI products before benefits
for a non-formulary PPI will be considered. Benefits
for formulary PPIs do not need to be pre-authorized.
Who will be automatically approved for
benefits under this program?
Benefits will be automatically approved for a non-
formulary PPI for patients who have had at least one
prescription filled for all three formulary PPIs within
the last 12 months.
If I am currently taking a non-formulary
PPI, what do I need to do? How does this
program affect my benefits?
If you are currently taking a non-formulary PPI
and it is not documented that you have tried all
three formulary PPIs without success during the
past 12 months, benefits for continued use of the
non-formulary PPI will not be available.
Please contact your doctor to discuss your therapy requirements. If your medical history indicates that changing to a formulary PPI is not appropriate for you, your doctor must submit a preauthorization request form to Blue Cross and Blue Shield of Nebraska for approval. If the preauthorization request is approved, you will be able to continue to purchase the non-formulary PPI for your plan’s non-formulary brand name out-of-pocket amount.
This benefit approval will be valid for 36 months.
The ultimate decision regarding your treatment rests with you and your doctor.
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