Request For Prior Authorization Form - Proton Pump Inhibitors - Highmark Blue Cross Blue Shield Delaware - Health Options
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2Request for Prior Authorization – Proton Pump Inhibitors
Website Form –
Submit request via: Fax ‐ 1‐855‐476‐4158
Client name _________________________________________ DOB: ________________________________________________
Medicaid ID Number: __________________________________ Date of Request:_______________________________________
Practitioner Name:____________________________________ NPI:__________________________________________________
Office Phone Number: _________________________________ Office Fax Number: ____________________________________
Preferred products do not require prior authorization for daily dosing. Clinical prior authorization is required for any other
proton pump inhibitor
New products with this classification will automatically require the same documentation. Proton Pump Inhibitors are
antisecretory compounds. They do not exhibit anticholinergic or histamine (H2) antagonistic properties, but suppress gastric acid
secretion. This class of drug is indicated for:
Covered Conditions
CATEGORY 1
GERD ‐ initial approval = 60 days
•
Duodenal Ulcer – initial approval = 60 days
•
Gastric Ulcer – initial approval = 60 days
•
Erosive Esophagitis – initial approval = 60 days
•
History of gastric ulcer and concurrent treatment with NSAID – initial approval = 60 days
•
CATEGORY 2
Laryngopharyngeal reflux disease – initial approval = 1 year
•
Barrett’s esophagus – initial approval = 1 year
•
Pathological hypersecretory conditions– initial approval = 1 year
•
Presence of gastric tube – initial approval = 1 year
•
Gastric hemorrhage and concurrent H2 antagonist therapy ‐ initial approval = 1 year
•
General Requirements
GERD requires treatment with histamine antagonist within 100 days of request for PPI
•
FDA approved dosing regimen (daily dose and duration)
•
Evidence of titration to lowest acid suppressive dose after 16 weeks of continued therapy
•
Documentation of evaluation of concurrent therapy with medications that exacerbate condition
•
Client must be evaluated for H.pylori and appropriately treated with antibiotic egimen with an ulcer diagnosis
•
Authorization for Additional 60 Days for category 1 diagnosis will require
Client must have demonstrated compliance with prescribed regimen
•
Requires documentation of lifestyle changes
•
Referral or consult with specialist
•
Revised 11/24/2015
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