Dexilant (dexlansoprazole) — Point32Health
gastroesophageal reflux disease
Preferred products
- omeprazole (Prilosec)
- pantoprazole (Protonix)
- lansoprazole (Prevacid)
- rabeprazole (Aciphex)
- esomeprazole (Nexium)
Initial criteria
- The patient has tried and failed or has a contraindication or intolerance to ALL of the following high dose PPIs: omeprazole (Prilosec) 40 mg daily, pantoprazole (Protonix) 80 mg daily, and one additional proton pump inhibitor (e.g., lansoprazole [Prevacid] 30 mg daily, rabeprazole [Aciphex] 20 mg, esomeprazole [Nexium] 40 mg daily)
Reauthorization criteria
- The patient continues to require the use of dexlansoprazole OR
- The patient is new to the plan, has been stable on the requested medication with another plan, and meets the initial criteria
Approval duration
initial 6 months; reauth 12 months