Important news about proton pump inhibitor (PPI) medications

Members will 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, Fallon 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 Fallon Direct Care, Fallon Select Care, and Fallon Preferred Care members. No matter what pharmacy plan a member is on they will be able to receive these prescriptions for a $5 copayment*

Also starting January 1, 2010, Fallon will remove the following PPI medications from our covered drug list: Prevacid, Prilosec, Protonix, Zegerid, lansoprazole, omeprazole and pantoprazole.

Fallon 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 Fallon’s formulary as Tier-3 drugs and will require prior authorization.

The savings
Members who take these medications may pay $45 or more a month for a prescription PPI costing at least $540 a year. By paying only a $5 copayment* for 42 tablets (about $43 for 1 year) for an over-the-counter version, members will be saving $497 a year. To take advantage of this cost-saving choice, members should get a new prescription from their PCP for one of the covered over-the-counter PPIs.

Questions members or providers may have about the PPI changes

 

Why is Fallon making this change?

Fallon 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 Fallon formulary?

Yes. We have added a new PPI medication called Dexilant (formerly known as Kapidex) 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 Fallon’s formulary as Tier-3 drugs requiring prior authorization. Your provider would have to submit a request for prior authorization to Fallon in order for you to obtain a prescription for either of these drugs.

How does this change save members money? How much?

If a member has been purchasing PPI medications, he or she may have been paying $45 or more a month for a prescription PPI. So, he or she 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, the member will be saving $497 or more a year. Also, if the member was paying out of pocket for these medications, the $5 copayment* will be considerably less than the standard retail price for over-the-counter PPIs.

If a members are on a qualified high deductible plan, how does this change help them save money?

If a member is on a qualified high deductible plan, please keep in mind that copayments only apply after your deductible is satisfied for the year. If their doctor agrees that over-the-counter PPI medication is right for them, they 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 their deductible is satisfied, members will pay a $5 copayment* for 42 tablets with a prescription from your doctor.           

My patient takes Prevacid, Prilosec, Protonix, Zegerid, lansoprazole, omeprazole or pantoprazole.  Since it will no longer be covered, what am I supposed to do?

First, you can discuss with him or her if an over-the-counter medication is right for them. All Fallon contracted providers have been notified of the change to cover prescriptions for over-the-counter PPI medications. If yes, then you can write a new prescription for one of the covered over-the-counter drugs and the patient can fill it at their local pharmacy for the $5 copayment*.

Will I need to write a new prescription for my patient to get over-the-counter drugs?

Yes, a new prescription will be needed for the member to get the over-the-counter drug for a $5 copayment*.

My patient has tried over-the-counter PPI drugs in the past and they didn’t work.  What other options are available?

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 Fallon formulary called Dexilant (formerly known as Kapidex).  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 Fallon’s formulary as Tier-3 drugs requiring prior authorization. Your provider will have to submit a request for prior authorization to Fallon in order for you to obtain a prescription for either of these drugs.

* Commonwealth of Massachusetts members have a $10 copayment for covered prescription over-the-counter PPI medication. MassHealth member copayments are $2.