CurrentMass General Brigham Health PlanPolicy N/A

Proton Pump Inhibitors (PPIs)

Defines step-therapy, prior authorization, and quantity limits for proton pump inhibitor medications under the pharmacy benefit for Mass General Brigham Health Plan members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyProton Pump Inhibitors (PPIs)

Policy CodePolicy N/A

Change TypeStep therapy and formulary updates

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionIf step therapy criteria are not met at point of sale, submit a prior authorization request; authorization may be granted when inadequate response or side effects to required prior agents are documented.

SourceLink

POLICY UPDATE CHANGES

Updated step therapy table to clarify dosage forms and Rx vs OTC status; esomeprazole strengths updated due to generic release; lansoprazole ODT and Konvomep now require step therapy for all members.

Added omeprazole/sodium bicarbonate oral powder for suspension to program as a second-line agent (previously effective 9/1/23) and updated Dexlansoprazole generic replacement notes.

3Step therapy tiers

30Common QL (many formulations)

90 daysNew-to-plan continuity window

180 daysLook-back period

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Coverage Criteria — When PPIs Are Covered

Step therapy and PA criteria

Covered when meeting the following step-therapy or prior authorization (PA) criteria.

Initial adjudication: If prescription is for a first-line medication listed, it will adjudicate automatically without prior authorization.

First-line agents listed in policy; automatic point-of-sale adjudication

Second-line coverage: Covered if member has filled at least two first-line medications OR one second-line medication within the past 180 days; or if there is documented inadequate response or side effects to two first-line medications or one second-line medication.180 days

Second-line agents listed in policy; see drug list for products

Third-line coverage: Covered if member has filled at least two second-line medications OR one third-line medication within the past 180 days; or if there is documented inadequate response or side effects to two second-line medications or one third-line medication.180 days

Third-line agents listed in policy; see drug list for products

New-to-plan continuity: Authorization may be granted for members new to the plan within the past 90 days who are currently receiving the requested medication (excluding samples or manufacturer patient assistance program drugs).90 days

Documentation of ongoing therapy required

Prilosec packets for suspension, pantoprazole packets for suspension, and esomeprazole packets for suspension will be covered for members <12 years of age without prior authorization. This pediatric exception applies only to the packets for suspension formulations specified in the policy.

Prescriptions that do not meet the initial step therapy requirements will be denied at the point of sale with a message indicating that prior authorization (PA) is required. Providers should submit a PA request for members who do not meet the initial step therapy criteria so the request can be reviewed against the PA criteria.

Provider Actions — Prior Authorization, Documentation, and Denials

Prior Authorization

Step therapy adjudication and PA at point of sale

Prescriptions that meet the initial step therapy requirements will adjudicate automatically at point of sale. If the prescription does not meet the initial step therapy requirements, the prescription will deny with a message indicating that prior authorization (PA) is required. Refer to the criteria below and submit a PA request for members who do not meet the initial step therapy requirements at the point of sale.

Step Therapy

Step therapy requirements

Initial step-therapy tiers and payment conditions. First-line medications are covered without prior authorization. Second-line medications will pay if the member has filled at least two first-line medications or one second-line medication within the past 180 days. Third-line medications will pay if the member has filled at least two second-line medications or one third-line medication within the past 180 days. Note: Prilosec packets for suspension, pantoprazole packets for suspension, and esomeprazole packets for suspension will be covered for members under 12 years of age without an authorization.

First-line: Covered without prior authorization
Second-line: Pay if ≥2 first-line fills OR ≥1 second-line fill in past 180 days

Initial Therapy (First-line) Criteria

Initial therapy (first-line)

First-line therapy is preferred and will adjudicate automatically.

First-line: Medications listed as first-line are covered without prior authorization at point of sale.

See policy drug list for first-line products (e.g., omeprazole capsules [Rx], pantoprazole tablets, omeprazole/sodium bicarbonate OTC capsules, lansoprazole, esomeprazole, rabeprazole as listed).

Continuation Therapy Criteria

Continuation therapy

Continuity for members new to the plan.

Current treatment continuation: Authorization may be granted for members new to the plan within the past 90 days who are currently receiving the requested medication (excluding samples or manufacturer patient assistance program drugs).90 days

Requires documentation of ongoing treatment from the previous plan or provider

Step Therapy Rules and Requirements

Look-back period	Required prior fills or documentation
180 days
Second-line: member must have filled at least two first-line medications OR one second-line medication within the past 180 days; OR documentation of inadequate response or side effects to two first-line medications or one second-line medication.
180 days
Third-line: member must have filled at least two second-line medications OR one third-line medication within the past 180 days; OR documentation of inadequate response or adverse effects to two second-line medications or one third-line medication.
90 days (new-to-plan continuity)
Authorization may be granted for members new to the plan within the past 90 days who are currently receiving the requested medication (documentation of ongoing treatment required; excludes samples and manufacturer patient assistance program drugs).

Product Coding and Quantity Limits

Pharmacy product codes and QL (NDC-level not enumerated)NDC

NDC	Various PPI NDCs and product-specific quantity limits are referenced in the drug list and limits.

Quantity limits — examples and general guidance

Common example QL30 capsules/packets/tablets per 30 days is the typical quantity limit for many PPI products (see product-specific limits below).

Product-specific variationSome products have higher limits (e.g., omeprazole 20 mg and esomeprazole capsules have limits up to 120 capsules per 30 days).

Liquid/suspension limitsKonvomep (oral suspension) is limited to 600 mL per 30 days.

Packet/ODT limitsCertain packets and ODT formulations have distinct limits (e.g., lansoprazole ODT 30 tablets/30 days; Prilosec packets 60 packets/30 days).

Actionable guidanceRefer to the product-specific quantity limits when submitting or dispensing PPI prescriptions to ensure claims adjudicate at point-of-sale.

Quantity Limits by Product

Omeprazole 10mg capsules — QL

Quantity limit30 capsules per 30 days

Unitcapsules

Source noteListed in policy limitations section as: 'Omeprazole 10mg capsules, 1 = 30 capsules per 30 days.'

Omeprazole 20mg capsules — QL

Quantity limit120 capsules per 30 days

Unitcapsules

Source noteListed in policy limitations section as: 'Omeprazole 20mg capsules, 1 = 120 capsules per 30 days.'

Definitions and Tiering

First-line / Second-line / Third-line definitions

First-line definitionMedications listed as first-line are covered without prior authorization at point of sale.

Second-line definitionSecond-line medications are covered if the member has filled at least two first-line medications OR one second-line medication within the past 180 days, or if there is documented inadequate response or side effects to the required prior agents.

Third-line definitionThird-line medications are covered if the member has filled at least two second-line medications OR one third-line medication within the past 180 days, or if there is documented inadequate response or adverse effects to the required prior agents.

Look-back period180 days applies to the fill-history requirement for second- and third-line coverage determinations.

Background

Proton pump inhibitors (PPIs) are used to reduce gastric acid production for typical acid-related conditions. This policy employs a step therapy approach to promote use of preferred first-line agents before higher-tier products: first-line medications listed in the policy will adjudicate automatically without prior authorization. Second- and third-line agents require evidence of prior fills within a 180-day look-back period (for example, two fills of the prior tier or one fill of the requested tier), or documentation of inadequate response or intolerance to required prior agents. If a prescription does not meet the initial step criteria at point of sale, it will deny and require a PA for review.

Policy Summary

PayerMass General Brigham Health Plan

PolicyProton Pump Inhibitors (PPIs)

Policy CodePolicy N/A

Change TypeStep therapy and formulary updates

Effective DateJun 1, 2025

Next Review DateN/A

SourceLink

On This Page

Third-line: Pay if ≥2 second-line fills OR ≥1 third-line fill in past 180 days

Age exception: Certain suspension packets covered for members <12 years without authorization

Documentation Required

New-to-plan continuity documentation

Members new to the plan (within the past 90 days) who are currently receiving treatment with the requested medication may be granted authorization to continue therapy. This does not apply when the product was obtained only as samples or via manufacturer's patient assistance programs. Documentation of prior use under the former plan (e.g., recent fill history, clinical notes) should be provided with the PA request to support continuity of therapy.

New-to-plan continuity: member enrolled ≤90 days and currently receiving medication
Exclude therapy obtained exclusively as samples or via patient assistance programs
Provide recent fill history or clinical documentation with PA request

Denial Risk

Point-of-sale denials when step therapy unmet

If the member does not meet initial step therapy requirements at point of sale, the claim will deny with instructions to submit a prior authorization. Requests for PA will be reviewed against the applicable prior authorization criteria, including documentation of inadequate response or intolerance to required prior therapy when applicable.

Point-of-sale denials: claim denies and indicates PA required when step therapy unmet
PA review will consider documented trials and intolerances per step-therapy criteria

Omeprazole 40mg capsules — QL

Quantity limit60 capsules per 30 days

Unitcapsules

Source noteListed in policy limitations section as: 'Omeprazole 40mg capsules, 1 = 60 capsules per 30 days.'

Pantoprazole 20mg tablets — QL

Quantity limit60 tablets per 30 days

Unittablets

Source noteListed in policy limitations section as: 'Pantoprazole tablets 20mg, 1 = 60 tablets per 30 days.'

Lansoprazole capsules (various strengths) — QL

Quantity limit120 capsules per 30 days

Unitcapsules

Source noteListed in policy limitations section as: 'Lansoprazole capsules 30mg 15mg, 1 = 120 capsules per 30 days.'

Esomeprazole capsules — QL

Quantity limit120 capsules per 30 days

Unitcapsules

Source noteListed in policy limitations section as: 'Esomeprazole capsules, 1 = 120 capsules per 30 days.'

Omeprazole/sodium bicarbonate capsules or packets — QL

Quantity limit30 capsules or 30 packets per 30 days

Unitcapsules/packets

Source noteListed in policy limitations section as: 'Omeprazole/sodium bicarbonate capsules, 1 = 30 capsules per 30 days. Omeprazole/sodium bicarbonate packets, 1 = 30 packets per 30 days.'

Rabeprazole tablets / sprinkles — QL

Quantity limit30 tablets or 30 sprinkles per 30 days

Unittablets/capsules (sprinkles)

Source noteListed in policy limitations section as: 'Rabeprazole tablets, 1 = 30 capsules per 30 days. Rabeprazole sprinkles, 1 = 30 capsules per 30 days.'

Dexlansoprazole capsules — QL

Quantity limit30 capsules per 30 days

Unitcapsules

Source noteListed in policy limitations section as: 'Dexlansoprazole capsules, 1 = 30 capsules per 30 days.'

Esomeprazole packets, Lansoprazole ODT, Pantoprazole packets, Prilosec packets — QL

Quantity limitsEsomeprazole packets = 30 packets/30 days; Lansoprazole ODT = 30 tablets/30 days; Pantoprazole packets = 30 packets/30 days; Prilosec packets = 60 packets/30 days

Unitpackets/tablets

Source noteListed in policy limitations section with each product-specific packet/ODT limit noted accordingly.'

Konvomep bottle — QL

Quantity limit600 mL per 30 days

UnitmL (oral suspension)

Source noteListed in policy limitations section as: 'Konvomep bottle, 1 = 600 mL per 30 days.'