Prior Authorization Program for Proton Pump Inhibitors

Effective June 1, 2007, the N.C. Medicaid pharmacy program requires prior authorization on proton pump inhibitor medications.  Medications that require prior authorization include Aciphex, Nexium, Prevacid, Prilosec, Protonix, Pantoprazole and Zegerid.

Prescribers can request prior authorization through ACS by contacting ACS at 866-246-8505 (telephone) or 866-246-8507 (fax).  A pharmacist can override the PA requirement at point-of-sale if the prescriber writes one of the following phrases on the face of the prescription:

• “Failed omeprazole 40mg for 30 days”
• “Esophagitis Grade C” – for esomeprazole magnesium (Nexium) 40mg prescriptions only
• “Esophagitis Grade D” – for esomeprazole magnesium (Nexium) 40mg prescriptions only
• “Cannot swallow tablets”
• “Cannot swallow capsules”

If a proton pump inhibitor medication has a generic version available, “medically necessary” must also be written on the face of the prescription in order to dispense the brand name drug.  Prior authorization is not required for recipients who are pregnant, breastfeeding or under 6 years old.

The criteria and PA request form for these medications are available on the N.C. Medicaid Enhanced Pharmacy Program website at http://www.ncmedicaidpbm.com.