Proton Pump Inhibitors (Ppis) Prior Authorization Request Form
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1
2Alabama Medicaid
Pharmacist
Prior Authorization Criteria for Proton Pump Inhibitors (PPIs)
Revised date 03/06/02
A newsletter service of Alabama Medicaid
GERD
May 2002
Published by Health Information Designs, Inc.
For symptomatically diagnosed, moderate to severe GERD that has not responded to a trial with lifestyle modifications and a minimum
of an 8 week course of treatment with OTC/generic/brand H2 antagonist and antacids, approval may be given for up to 4 weeks of
acute therapy. Lifestyle Modifications include elevation of the head of the bed (on 6 inch blocks or foam wedge), avoiding lying down
within 3 hours after meals, avoiding acidic foods (tomato products, citrus fruits, spicy foods, coffee) and agents that relax the lower
DEPAKOTE ER
Characteristics of Forged Prescriptions*
esophageal sphincter or delay gastric emptying time (fatty foods, peppermint, chocolate, alcohol, smoking), weight loss, avoidance of
bending after meals, and reduction of meal size. Moderate to severe means patients with > 2 episodes/week of nocturnal heartburn,
• Prescription looks “too good”; the prescriber’s
When dispensing more than 60 units for a 30
and > 3 episodes/week of daytime heartburn or indigestion, with no resolution or worsening of symptoms. If severe GERD symptoms
day supply of Depakote ER, you may get a
handwriting is too legible.
persist, and there is documentation of lifestyle modifications, approval may be given for an additional 8 weeks of treatment.
• Quantities, directions or dosages differ from usual
DUR alert. This is a soft edit that can be over-
Peptic Ulcer Disease
ridden by the pharmacist. It is not necessary to
medical usage.
If the patient has tested positive for H pylori, approval may be given for up to a 4 week course of treatment when there is documenta-
contact HID for an override.
• Prescription does not comply with acceptable
tion of combination therapy. If the patient has been diagnosed with an active duodenal ulcer by endoscopy or UGI, up to 4 weeks of
standard abbreviations.
acute therapy may be approved. If the patient has been diagnosed with an active gastric ulcer by endoscopy or UGI, up to 8 weeks of
• Prescription appears to be photocopied.
The pharmacist can use the following Soft Edit
acute therapy may be approved. If severe symptoms persist and there is documentation of lifestyle changes, an additional 8 weeks of
treatment may be approved for duodenal ulcers and for gastric ulcers.
Codes:
• Directions written in full with no abbreviations.
• Prescription written in different color inks or writ-
Hypersecretory Conditions
HD for High Dose
ten in different handwriting.
If the patient is diagnosed with Barrett’s Esophagus, Zollinger-Ellison, or other hypersecretory disorders, which have been confirmed
R0 for Other source
by testing, then approval of up to 12 months of acute treatment may be issued, with continued maintenance therapy approved in 12
1G for filled with provider approval
month increments.
Additional medical justification for consideration for approval outside criteria may be attached, including medical justification for
This should allow the prescriptions to be pro-
the absence of lifestyle modifications in debilitated patients (i.e., nursing home patients).
Fraud Prevention Techniques*
cessed.
Know the prescriber and his or her signature.
Know the prescriber’s DEA registration number.
Know the patient .
CHARGING RECIPIENTS CASH
Check the date on the prescription order. Has it
FOR PRESCRIPTION QUANTITIES
been presented to you in a reasonable length of
EXCEEDING MEDICAID’S
time since the prescriber wrote it?
MONTHLY MAXIMUM QUANTITY
When there is a question concerning any aspect
of the prescription order, call the prescriber for
If a patient presents a prescription for more than
verification or clarification.
the monthly limit, the pharmacy or physician should
contact HID for an override. A Medicaid patient
*A Pharmacist’s Guide to Prescription Fraud: U.S. Depart-
cannot be charged cash for quantities in excess
ment of Justice, Drug Enforcement Administration, Diver-
of the established monthly maximum limit unless
sion Control Program
an override has been requested and denied.
Whether all or a portion of the quantity requested
Medicaid Fruad Hotline
- 1-800-824-6584
is denied by HID, the amount denied is consid-
ered a non-covered Medicaid service for that
patient. The provider may charge cash for a Med-
icaid non-covered service. Any questions regard-
For copies of all PA forms log on
ing this notice may be directed to Program Man-
to the Alabama Medicaid website:
agement at 334-242-5050
or
..................................................
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