Texas Prior Authorization Program Clinical Criteria. This criteria was recommended for review by an MCO to ensure appropriate and safe utilization.

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Texas Prior Authorization Program Clinical Criteria Drug/Drug Class This criteria was recommended for review by an MCO to ensure appropriate and safe utilization.

description of how the prior authorization request will be evaluated against the clinical criteria rules Logic diagram: a visual depiction of the clinical criteria logic Supporting tables: a

1 Texas Prior Authorization Program Clinical Criteria Drug/Drug Class This criteria was recommended for review by an MCO to ensure appropriate and safe utilization. Clinical Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical criteria rules Logic diagram: a visual depiction of the clinical criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes); provided when applicable References: clinical publications and sources relevant to this clinical criteria Note: Click the hyperlink to navigate directly to that section Revision Notes January 26, 2018 Copyright Health Information Designs, LLC 1

2 Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization Label Name GCN ACIPHEX DR 20 MG TABLET ACIPHEX SPRINKLE DR 10 MG CAP ACIPHEX SPRINKLE DR 5 MG CAP DEXILANT DR 30 MG CAPSULE DEXILANT DR 60 MG CAPSULE ESOMEPRAZOLE MAG DR 20 MG CAP ESOMEPRAZOLE MAG DR 40 MG CAP ESOMEPRAZOLE SODIUM 20 MG VIAL LANSOPRAZOLE DR 15 MG CAPSULE LANSOPRAZOLE DR 30 MG CAPSULE NEXIUM DR 10 MG PACKET NEXIUM DR 2.5 MG PACKET NEXIUM DR 20 MG CAPSULE NEXIUM DR 20 MG CAPSULE NEXIUM DR 20 MG PACKET NEXIUM DR 40 MG PACKET NEXIUM DR 5 MG PACKET OMEPRAZOLE DR 10 MG CAPSULE OMEPRAZOLE DR 20 MG CAPSULE OMEPRAZOLE DR 20 MG TABLET OMEPRAZOLE DR 40 MG CAPSULE OMEPRAZOLE MAG DR 20.6 MG CAP OMEPRAZOLE-BICARB CAP OMEPRAZOLE-BICARB PKT OMEPRAZOLE-BICARB CAP OMEPRAZOLE-BICARB PKT PANTOPRAZOLE SOD DR 20 MG TAB PANTOPRAZOLE SOD DR 40 MG TAB PREVACID 15 MG SOLUTAB PREVACID 30 MG SOLUTAB PREVACID DR 15 MG CAPSULE PREVACID DR 30 MG CAPSULE January 26, 2018 Copyright Health Information Designs, LLC 2

3 Drugs Requiring Prior Authorization Label Name GCN PROTONIX 40 MG SUSPENSION PROTONIX DR 20 MG TABLET PROTONIX DR 40 MG TABLET PROTONIX IV 40 MG VIAL RABEPRAZOLE SOD DR 20 MG TAB ZEGERID 20 MG CAPSULE ZEGERID 20 MG PACKET ZEGERID 40 MG CAPSULE ZEGERID 40 MG PACKET January 26, 2018 Copyright Health Information Designs, LLC 3

4 Clinical Criteria Logic 1. Does the client have a diagnosis of Zollinger-Ellison syndrome or Barrett s esophagus in the last 730 days? [ ] Yes (Approve 90 days) [ ] No (Go to #2) 2. Does the client have greater than or equal to ( ) 120 days therapy in the last 365 days? [ ] Yes (Deny) [ ] No (Approve 90 days) January 26, 2018 Copyright Health Information Designs, LLC 4

Clinical Criteria Logic Diagram Step 1 Step 2 Does the client have a diagnosis of Zollinger- Ellison syndrome or Barrett s esophagus in the last 730 days?

5 Clinical Criteria Logic Diagram Step 1 Step 2 Does the client have a diagnosis of Zollinger- Ellison syndrome or Barrett s esophagus in the last 730 days? No Does the client have 120 days therapy in the last 365 days? Yes Deny Request Yes No Approve Request (90 days) Approve Request (90 days) January 26, 2018 Copyright Health Information Designs, LLC 5

6 Clinical Criteria Supporting Tables Step 1 (diagnosis of Zollinger-Ellison syndrome or Barrett s esophagus ) Required diagnosis: 1 Look back timeframe: 730 days ICD-10 Code Description E164 K2270 K22710 K22711 K22719 ZOLLINGER-ELLISON SYNDROME BARRETT'S ESOPHAGUS WITHOUT DYSPLASIA BARRETT'S ESOPHAGUS WITH LOW GRADE DYSPLASIA BARRETT'S ESOPHAGUS WITH HIGH GRADE DYSPLASIA BARRETT'S ESOPHAGUS WITH DYSPLASIA UNSPECIFIED January 26, 2018 Copyright Health Information Designs, LLC 6

7 Clinical Criteria References ICD-10-CM Diagnosis Codes Available at Accessed on December 5, Clinical Pharmacology [online database]. Tampa, FL: Elsevier/Gold Standard, Inc.; Available at Accessed on December 5, Micromedex [online database] Available at Accessed on December 5, Bergsland E (2017). Management and prognosis of the Zollinger-Ellison syndrome (gastrinoma). S. Grover (Ed.), UpToDate. Retrieved December 5, 2017 from 5. Spechler SJ (2017). Barrett s esophagus: Surveillance and management. K. Robson (Ed.), UpToDate. Retrieved December 5, 2017 from 6. Shaheen NJ, Falk GW, Iyer PG, et al. ACG Clinical Guideline: Diagnosis and management of Barrett s Esophagus. Am J Gastroenterol. 3 Nov 2015; Moayyedi PM, Lacy BE, Andrews CN, et al. ACG and CAG Clinical Guideline: Management of Dyspepsia. Am J Gastroenterol. 20 June 2017; Katz PO, Gerson LB, Vela MF. Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol 2013: 108: Chey WD, Leontiadis GI, Howden CW, et al. ACG Clinical Guideline: Treatment of Heliobacter pylori Infection. Am J Gastroenterol 2017; 112: Spechler SJ, Sharma P, Souza RF, et al. American Gastroenterological Association Medical Position Statement on the Management of Barrett s Esophagus. Gastroenterology 2011;140: January 26, 2018 Copyright Health Information Designs, LLC 7

8 Publication History The Publication History records the publication iterations and revisions to this document. Notes for the most current revision are also provided in the Revision Notes on the first page of this document. Publication Date Notes 01/26/18 Initial publication and presentation to the DUR Board January 26, 2018 Copyright Health Information Designs, LLC 8

Drug Class Monograph

Drug Class Monograph Class: Proton Pump Inhibitors Drugs: Aciphex Sprinkle (rabeprazole), Dexilant (dexlansoprazole), Lansoprazole, Nexium (esomeprazole capsule, esomeprazole granules), Omeprazole, Pantoprazole,