AcipHex — CareFirst (Caremark)

Initial criteria

• Authorization may be granted when ONE of the following is met:
• 1. Barrett’s esophagus confirmed by biopsy
• 2. Hypersecretory syndrome such as Zollinger-Ellison confirmed with a diagnostic test
• 3. Endoscopically verified peptic ulcer disease
• 4. Frequent and severe symptoms of chronic gastroesophageal reflux disease (GERD)
• 5. Atypical symptoms or complications of GERD (maintenance of healing of erosive esophagitis, maintenance of healing of duodenal ulcers)
• 6. Patient is at high risk for gastrointestinal adverse events (risk factors include eosinophilic esophagitis, chronic NSAID therapy, history of peptic ulcer disease and/or GI bleeding, treatment with oral corticosteroids, treatment with anticoagulants, poor general health status, or advanced age)

Reauthorization criteria

• Continuation may be approved if the patient continues to meet initial criteria for the indicated condition

Approval duration

Indefinite or Lifetime for Barrett’s esophagus or Zollinger-Ellison syndrome; 36 months for other indications