proton pump inhibitor suspensions, granules, packets, and orally disintegrating formulations — Point32Health

Preferred products

• omeprazole suspension
• lansoprazole suspension

Initial criteria

• Documentation of swallowing disorder AND
• The patient has had a trial and failure with, or contraindication or intolerance to omeprazole suspension or lansoprazole suspension

Reauthorization criteria

• The patient continues to require the use of a proton pump inhibitor suspension, granule, packet, or orally disintegrating formulation 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