Gastro Intestinal

Tier 1 products are available with no authorization necessary.

Criteria for Approval of a Tier 2 medication:

• A 14 day trial of all available tier 1 medications titrated up to the recommended dose that has resulted in inadequate relief of symptoms or intolerable adverse effects.
• Contraindication to all available tier 1 medications.
• An indication not covered by lower tiered medications.

Criteria for Approval of a Tier 3 medication:

• A 14 day trial all available tier 2 medications that has resulted in inadequate relief of symptoms or intolerable adverse effects.
• Contraindication to all available tier 2 medications.
• An indication not covered by lower tiered medications.

Criteria for Approval of Age Appropriate PPIs for Pediatric members under the age of 19:

• A recent 14 day trial of an H2 receptor antagonist that has resulted in inadequate relief of symptoms or intolerable adverse effects.
• Recurrent or severe disease such as:
  • GI Bleed
  • Zollinger-Ellison or similar disease
• Prior Authorization form

Special Prior Authorizations of Miscellaneous Products

• ranitidine (Zantac® Effervescent Tabs) - must have reason why member cannot take other dosage forms.
• famotidine (Pepcid® Suspension) - reserved for members less than 1 month old.

Tier 1

Tier 2

Tier 3

• omeprazole (Prilosec® 10 mg, 20 mg & 40 mg caps)
• pantoprazole (Protonix® Tabs)

• dexlansoprazole (Dexilant®)
• lansoprazole (Prevacid® Caps and ODT)***

• omeprazole/antacid 
• esomeprazole (Nexium® Caps and I.V.)***
• omeprazole (Prilosec ® Susp)***
• pantoprazole (Protonix® Susp & I.V.)***
• rabeprazole sodium (Aciphex® Tabs)

Mandatory Generic Plan Applies:

***Special Formulations including ODTs, Granules, Suspension and Solution for I.V. require special reason for use.

PA criteria:

• Chronic Idiopathic Constipation in males and females, or Irritable bowel syndrome in females 18 years of age and older who meet the following criteria:
  • Have documentation that constipating inducing therapies for other disease states have been discontinued (excluding opioid pain medications for cancer patients).
  • Documented and updated Colon Screening. (>50 years of age)
• Hydration and treatment attempts with a minimum of three alternate products must be documented.
• Initial approval for 12 weeks of therapy. An additional year approval may be granted if physician documents member is responding well to treatment.
• Quantity limit of 100 units for a 50 day supply.

granisetron (Kytril®, Sancuso®), dolasetron (Anzement®), aprepitant (Emend®)

Approval Criteria:

• Approved Diagnosis
• A recent (within the past 6 months) trial of ondansetron used for at least 3 days or one cycle that resulted in inadequate response.

nabilone (Cesamet®), dronabinol (Marinol®)

Approval Criteria:

• For the diagnosis of HIV related loss of appetite: approve for 6 months
• For chemotherapy induced nausea and vomiting: A recent (within the past 6 months) trial of ondansetron used for at least 3 days or one cycle that resulted in inadequate response.

Zuplenz™
Approval Criteria:
     

• FDA approved indication.
• Must provide clinically significant reason why the member cannot take all other available formulations of generic ondansetron.