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Dexilant — CareFirst (Caremark)

Frequent and severe symptoms of chronic gastroesophageal reflux disease (GERD)

Initial criteria

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

Approval duration

Indefinite or Lifetime for Barrett’s esophagus and Hypersecretory syndrome; 36 months for other indications under policy 169-J (12 months for MMT 918-J)