Dexilant — CareFirst (Caremark)

High risk for gastrointestinal adverse events

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)

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

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