NEW: PDL Changes for Proton Pump Inhibitors

Date: 07/18/19

Superior HealthPlan is committed to providing appropriate, high-quality and cost-effective drug therapy to all members. Superior covers prescription medications as outlined by the Texas Medicaid and CHIP Vendor Drug Program (VDP). Proton Pump Inhibitors (PPI) are a class of medications that are commonly used to help treat gastroesophageal reflex disease and other acid-related conditions. There is a variety of medication options within the PPI class and the majority of the medications are now available in a generic formulation.

At the end of July, the VDP will be moving brand Nexium (esomeprazole) oral capsules from Preferred (PDL) to Non-Preferred (NPD) status on the Texas Medicaid STAR formulary. Generic pantoprazole tablets and generic omeprazole capsules will remain as the preferred (PDL) products within the PPI class of medications. Nexium granule packets will remain in a preferred status as well. For all preferred medications, please refer to the VDP Preferred Drug List.

Please note, there is a PPI clinical edit (prior authorization) required on all proton pump inhibitors for extended use. Extended use is defined as ≥120 days of therapy in the past 365 days. The exception to the day supply limit is if the patient has a diagnosis of Zollinger-Ellison Syndrome or Barrett’s esophagus. The majority of patients should only be on PPIs for a short duration as there are long term health concerns with chronic use of PPIs such as increased risks for Clostridioides difficile, fractures/osteoporosis, and dementia. Please reference the PPI Risks associated with chronic use of PPIs for more information.

Useful Provider Tips:

Providers should consider: Why is this patient on the medication? Is a PPI really needed?
Long term use of PPI has clinical concerns, use shortest duration.
Prior authorization will be required for any extended use (≥120 day supply in last 365 days), unless the patient has a diagnosis of Zollinger-Ellison Syndrome or Barrett’s Esophagus.
Use preferred PDL alternatives.

For more information or questions regarding this information, please contact the Superior Pharmacy Department at 1-800-218-7453, ext. 22080 or 22272.