Important news about proton pump inhibitor (PPI) medications
You'll pay less for the same acid relief
Studies and medical experts agree—if you currently take a proton pump inhibitor (PPI) medication such as Aciphex®, Nexium®, omeprazole, pantoprazole, Prevacid, Prevacid® Solutabs™, Prilosec®, Protonix®, or Zegerid® for stomach acid conditions, you’ll get just as much relief from an over-the-counter PPI.
Starting January 1, 2010, FCHP will cover prescriptions for the following over-the-counter PPIs: Prilosec OTC®, Prevacid® 24HR and generic over-the-counter omeprazole. These prescriptions will be covered with just a $5 copayment* for 42 tablets for FCHP Direct Care, FCHP Select Care, FCHP Commonwealth Care, and Fallon Preferred Care members.
Also starting January 1, 2010, FCHP will remove the following PPI medications from our covered drug list: Prevacid, Prilosec, Protonix, Zegerid, lansoprazole, omeprazole and pantoprazole.
FCHP has added a new prescription PPI called Dexilant® (formerly known as Kapidex™) to our formulary. Dexilant is covered as a Tier-3 drug with the applicable Tier-3 copayment. Two other PPI drugs, Aciphex and Nexium, remain on FCHP’s formulary as Tier-3 drugs and will require prior authorization.
You may currently pay $45 or more a month for a prescription PPI, costing a total of at least $540 a year. By paying only a $5 copayment* for 42 tablets (about $43 for one year) for an over-the-counter version, you'll save $497 a year. To take advantage of this cost-saving choice, you should get a new prescription from your primary care physician for one of the covered over-the-counter PPIs.
Questions you may have about the PPI changes
Why is FCHP making this change?
FCHP is making this change to offer our members a cost savings by covering over-the-counter PPI medications with a $5 copayment*. Prilosec OTC, omeprazole OTC and the new Prevacid 24HR are available over-the-counter in the same dosage as the prescription versions. Studies and medical experts agree that they work just as well and are just as safe, but have a much lower retail price than prescription versions. For more information, you can read Consumer Reports summary article: Evaluating Drugs to Treat Heartburn, Gastric Ulcers and Stomach Acid Reflux: The Proton Pump Inhibitors. Comparing Effectiveness, Safety and Price (pdf).
Will any of the drugs in the class be covered under the FCHP formulary?
Yes. We have added a new PPI medication called Dexilant to our formulary as a Tier-3 drug effective January 1, 2010. The applicable Tier-3 copayment will apply.
Two other drugs, Aciphex and Nexium, remain on FCHP’s formulary as Tier-3 drugs requiring prior authorization. Your provider would have to submit a request for prior authorization to FCHP in order for you to obtain a prescription for either of these drugs.
How does this change save me money? How much can I save?
If you have been purchasing PPI medications, you may have been paying $45 or more a month for a prescription PPI. So, you would have paid at least $540 a year for this prescription. By paying only a $5 copayment* for a 42 day supply (about $43 for one year) of an over-the-counter version, you will be saving $497 or more a year. Also, if you were paying out of pocket for these medications, the $5 copayment* will be considerably less than the standard retail price for over-the-counter PPIs.
I am on a qualified high deductible plan, how does this change help me save money?
If you are on a qualified high deductible plan, please keep in mind that copayments only apply after your deductible is satisfied for the year. If your doctor agrees that over-the-counter PPI medication is right for you, you will be paying less for the over-the-counter version since these drugs have a much lower retail price than the brand name prescription versions. Once your deductible is satisfied, you'll pay a $5 copayment* for 42 tablets with a prescription from your doctor.
I take Prevacid, Prilosec, Protonix, Zegerid, lansoprazole, omeprazole or pantoprazole. Since it will no longer be covered, what am I supposed to do?
First, ask your doctor if an over-the-counter medication is right for you. All FCHP contracted providers have been notified of the change to cover prescriptions for over-the-counter PPI medications. If your doctor agrees that an over-the-counter medication is right for you, he or she can write a new prescription for one of the covered over-the-counter drugs which you can fill at your local pharmacy for the $5 copayment*.
Will I need a new prescription from my doctor to get over-the-counter drugs?
If your doctor agrees that an over-the-counter medication is right for you, he or she can write a new prescription for one of the covered over-the-counter drugs which you can fill at your local pharmacy for the $5 copayment*.
I’ve tried over-the-counter PPI drugs in the past and they didn’t work. What should I do?
Please talk to your doctor about which over-the-counter PPI may work for you. You can also ask your doctor about a new PPI drug that has been added to the FCHP formulary called Dexilant. This drug is a Tier-3 drug. If your doctor writes you a prescription for Dexilant, you can fill the prescription at your local pharmacy and pay your Tier-3 copayment.
Two other PPI drugs, Aciphex and Nexium, remain on FCHP’s formulary as Tier-3 drugs requiring prior authorization. Your provider will have to submit a request for prior authorization to FCHP in order for you to obtain a prescription for either of these drugs.
I’ve discussed my options with my physician, and he/she wants me to keep taking my brand name PPI. What can I do?
Your doctor has been notified that Prevacid, Prilosec, Protonix, Zegerid, lansoprazole, omeprazole and pantoprazole have been removed from the FCHP formulary. The brand name PPIs that remain on the FCHP formulary are Dexilant, Aciphex and Nexium.
If your doctor believes you should be taking a brand name prescription PPI drug, he may write you a prescription for one of the PPIs that remain on the FCHP formulary.
Dexilant does not require a prior authorization from the plan. However, Aciphex and Nexium do require a prior authorization. Your doctor would have to complete a prior authorization form for Aciphex or Nexium and submit it as instructed on the form. If the authorization is approved, you will be able to obtain Aciphex or Nexium for your Tier-3 copayment.
If my physician submits a prior authorization form, is it automatically approved?
No. Drugs requiring a prior authorization must be approved by FCHP.
* Commonwealth of Massachusetts members have a $10 copayment for covered prescription over-the-counter PPI medication. MassHealth member copayments are $2.