Dexilant (dexlansoprazole) — CareFirst (Caremark)
High risk for gastrointestinal (GI) adverse events
Initial criteria
- Authorization may be granted when ONE of the following criteria are met:
- • Barrett’s esophagus confirmed by biopsy OR
- • Hypersecretory syndrome such as Zollinger-Ellison confirmed with a diagnostic test OR
- • Endoscopically verified peptic ulcer disease OR
- • Frequent and severe symptoms of chronic GERD OR
- • Atypical symptoms or complications of GERD (maintenance of healing of erosive esophagitis, maintenance of healing of duodenal ulcers) OR
- • Patient at high risk for GI adverse events (risk factors include eosinophilic esophagitis, chronic NSAID therapy, history of peptic ulcer disease or GI bleeding, oral corticosteroid use, anticoagulant use, poor general health status, or advanced age)
Reauthorization criteria
- Continuation may be approved if the member continues to meet initial criteria
Approval duration
36 months (169-J) for all indications except Barrett’s esophagus and hypersecretory syndrome which are Indefinite/Lifetime