CurrentMass General Brigham Health PlanPolicy N/A

Pediatric proton pump inhibitor (PPI) formulary guidance

Lists MassHealth PPI products, age/quantity limits, and which products are available via SmartPA or without prior authorization for pediatric patients; intended for pediatric clinicians prescribing PPIs to MassHealth members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyPediatric proton pump inhibitor (PPI) formulary guidance

Policy CodePolicy N/A

Change TypeAdministrative update — availability listing

Effective DateMay 12, 2025

Next Review DateN/A

Key ActionUse SmartPA-available products or submit a prior authorization with supporting medical records for non-listed PPI products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multiplePPI products listed for pediatric use

age-basedDose/unit limits

availableSmartPA availability

2025-05-12Effective date

Pediatric PPI Coverage and Availability

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For smaller patients (<=20 mg per dose): Nexium (esomeprazole) powder for suspension 2.5 mg, 5 mg, or 10 mg packets (brand over generic list; limit 1 unit/day if age >=2 years); Lansoprazole delayed release 15 mg capsule (limit 1 unit/day) — can be sprinkled on food or in juice; Prevacid (lansoprazole delayed release) 15 mg ODT (brand over generic list) — can be dissolved in water and administered by syringe; Omeprazole delayed release 10 mg capsule (limit 1 unit/day) — can be sprinkled on food; Omeprazole delayed release 20 mg capsule (limit 4 units/day) — can be sprinkled on food; Omeprazole + sodium bicarbonate powder for suspension 20 mg / 1680 mg packet (not FDA approved for pediatric use; sometimes used).age and per-dose mg limits

Formulation-specific administration notes included

For larger patients (>20 mg per dose) or when tablets/whole capsules cannot be used: Esomeprazole magnesium 20 mg or 40 mg capsule (limit 1 unit/day if age >=13 years) — can be sprinkled on food but not chewed; Lansoprazole delayed release 30 mg capsule (limit 1 unit/day if age >=13 years) — can be sprinkled on food or in juice; Prevacid (lansoprazole delayed release) 30 mg ODT (brand over generic list) — can be dissolved in water and administered by syringe; Omeprazole + sodium bicarbonate powder for suspension 40 mg / 1680 mg packet (not FDA approved for pediatric use; sometimes used off-label); Omeprazole delayed release 40 mg capsule (limit 2 units/day) — can be sprinkled on food; Protonix (pantoprazole) 40 mg powder for suspension (brand over generic list).age >=13 for some limits

Includes items sometimes used off-label

When tablets or whole capsules are appropriate: Esomeprazole magnesium 20 mg or 40 mg capsule; Lansoprazole delayed release 15 mg or 30 mg capsule (limits apply if age >=13 years); Prevacid (lansoprazole delayed release) 15 mg or 30 mg ODT (brand over generic list); Omeprazole delayed release 20 mg or 40 mg capsule (unit limits if age >=13 years); Omeprazole + sodium bicarbonate 20 mg/1100 mg or 40 mg/1100 mg capsule (not FDA approved for pediatric use; capsule should not be opened); Pantoprazole 20 mg or 40 mg tablet (limit 4 units/day if age >=13 years); Rabeprazole delayed release 20 mg tablet (limit 1 unit/day if age >=13 years).age >=13 for tablet/capsule limits

Includes capsule-specific handling guidance

Products or quantities beyond those listed on this guidance require prior authorization through the MassHealth Drug List (MHDL) process. When a patient’s needs cannot be met with the products and quantity limits shown, other PPI products are available on the MHDL with prior authorization (PA). Submit a PA request via the MHDL and include medical records documenting that the criteria for approval are met, referencing the product therapeutic detail page.

Prescriber Responsibilities and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior Authorization Required for non-listed PPI products. If a prescriber writes a prescription for a PPI that is not covered by SmartPA or listed as available without PA on the MassHealth Drug List (MHDL), a prior authorization is required. Check the MHDL for current SmartPA-covered products before prescribing alternative PPIs.

When products are not covered by SmartPA or listed as PA-exempt on the MHDL, submit a PA.
Effective Date: 2025-05-12

Prior Authorization

DAW-1 Triggers Prior Authorization

Prescribers must be aware that marking a prescription 'brand name necessary' or using DAW-1 will trigger a prior authorization. Do not write DAW-1 when ordering drugs on MassHealth's brand-preferred-over-generic list; pharmacists may dispense a brand-preferred product for a prescription written generically by submitting DAW-9.

Prescriptions with DAW-1 ('brand name only'/'dispense as written') will trigger PA.
Use DAW-9 for pharmacist substitution when appropriate.

Documentation Required

PA Documentation Required

PA documentation — include clinical records that demonstrate the patient’s need for the non-SmartPA PPI and that the MassHealth criteria for approval are met. Provide relevant medical records, prior medication trials, and any supporting clinical notes or test results.

Include medical records documenting trial/failure of SmartPA or PA-exempt products when applicable.
Reference the MHDL PA criteria: https://mhdl.pharmacy.services.conduent.com/MHDL/pubtheradetail.do?id=3

Note

Prescriber Responsibilities — MHDL Guidance

Provider-impact highlight: follow MassHealth Drug List guidance when prescribing. The MHDL is the authoritative source for which PPI products are available via SmartPA or without PA; consult it before ordering to avoid unnecessary PA requests or delays in therapy.

Consult the MHDL for current SmartPA and PA-exempt listings before prescribing.
If patient needs cannot be met with listed products, submit PA with documentation.

Clinical Background

Proton pump inhibitors (PPIs) are used in pediatric patients for acid-related conditions. MassHealth provides age- and product-specific guidance to support appropriate dispensing for children, including formulation and quantity limits and administration considerations (for example, options for sprinkling, oral disintegrating tablets, or feeding-tube compatibility where noted).

Prescribers should follow MassHealth’s brand-preferred guidance when ordering; do not write 'brand name necessary' or use a 'dispense as written' (DAW-1) flag, because DAW-1 will trigger a prior authorization. Pharmacists may dispense brand-preferred products when the prescription is written using the generic name by submitting DAW-9.

Key Terms

SmartPA — automated pharmacy authorization (definition and brief explanation)

DefinitionAn automated pharmacy authorization process that does not require a request from the prescriber.

How it worksSmartPA permits certain listed PPI formulations to be authorized at the pharmacy level automatically when dispensing criteria (formulation, age, quantity limits) are met, avoiding a separate prescriber-initiated PA.

When requiredIf a patient's needs cannot be met with SmartPA-eligible products or quantities, other PPI products on the MassHealth Drug List require prior authorization via the MHDL process.

DocumentationFor non-SmartPA PAs, provide medical records demonstrating criteria for approval and reference the MassHealth Drug List therapeutic detail page.

DAW-1 / DAW-9 — dispense-as-written codes and PA implications

DAW-1Dispense as written — 'brand name only' or 'brand medically necessary' flag; prescriptions written with DAW-1 will trigger a prior authorization.

DAW-9Allows pharmacists to dispense a brand-preferred product when the prescription is written using the generic name by submitting code DAW-9.

Prescriber guidanceWhen ordering drugs on MassHealth's brand preferred over generic list, prescribers should not write 'brand name necessary' or use DAW-1 to avoid triggering PA.