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Gastro Intestinal

Anti-Ulcer

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.

lubiprostone (Amitiza®)

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.
Anti - emetic

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.

If you have questions please call the Pharmacy Help Desk at (800) 522-0114 option 4 or (405) 522-6205 option 4.

Last Modified on Dec 02, 2020
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