Acid Suppression - Essential

Restriction applies to brand and generic products

• Dexilant® (dexlansoprazole) capsules
• Voquezna (vonoprazan) tablets 

• For the treatment of erosive esophagitis 
• For maintaining healing of erosive esophagitis and relief of heartburn 
• For treating heartburn associated with symptomatic non-erosive gastroesophageal reflux disease

1. The request is for Dexilant (dexlansoprazole); AND
   1. The patient has tried and failed TWO over-the-counter proton pump inhibitors (e.g., Nexium OTC, Prevacid OTC, etc.); OR 
      1. The patient has a clinical intolerance/contraindication to ALL over-the-counter proton pump inhibitors; AND 
   2. The patient has tried and failed pantoprazole; OR; 
      1. The patient has a clinical intolerance/contraindication to pantoprazole; OR
2. The request is for Voquezna (vonoprazan); AND
   1. The patient has tried and failed TWO over-the-counter proton pump inhibitors (e.g., Nexium OTC, Prevacid OTC, etc.); OR
      1. The patient has a clinical intolerance/contraindication to ALL over-the-counter proton pump inhibitors; AND
3. For formularies that exclude (non-formulary) the requested medication, Non-formulary Exception Criteria applies. 

Duration of Approval: 1 year (365 days)

All information referenced is from FDA package insert unless otherwise noted below.

Criteria and treatment protocols are reviewed annually by the Blue Cross NC P&T Committee, regardless of change. This policy is reviewed in Q2 annually.

January 2025: Criteria change: Removed pantoprazole and rabeprazole from the policy. Changed criteria for dexlansoprazole to include step through two OTC PPIs and pantoprazole. Updated FDA Approved Use section.

November 2023: Criteria change: Changed policy name from Proton Pump Inhibitors to Acid Suppression. Add new to market Voquezna tablets to the policy.

March 2023: Criteria update: Removed Esomeprazole Strontium from the policy.

February 2023: Criteria change: Removed preference of Brand Dexilant for generic dexlansoprazole requests.

February 2023: Criteria update: Removed Dexlansoprazole (authorized generic Dexilant) from the policy.

December 2022: Criteria update: Added new dexlansoprazole (generic Dexilant) to the policy.

January 2022: Criteria update: Added new Dexlansoprazole (authorized generic Dexilant) to the policy.

January 2022: Criteria update: Added Esomeprazole Strontium back to policy.

July 2021: Criteria update: Addition of Aciphex and Protonix to policy. Removed Esomeprazole Strontium from policy. Duration of approval changed to 1 year.

January 2021: Criteria update: Removed Aciphex sprinkles, Prilosec oral suspension, Protonix suspension packets, and rabeprazole sprinkles to separate policy.

Aug 2020: Criteria update: Removed unrestricted alternatives from the policy.

Apr 2020: Criteria Update: Removed ranitidine syrup from unrestricted section due to removal from market.

July 2019: Criteria Update: Addition of Rabeprazole (authorized generic for Aciphex Sprinkle) to policy.

Apr 2018: PPI’s removed from “Restricted Access Utilization Management Criteria” and placed on separate policy; Dexilant moved to a single prerequisite on Essential formulary. Removed Prevacid Solutab from policy due to generic availability.