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Proton Pump Inhibitors

Drug - Proton Pump Inhibitors (PPIs)

October 2015

Therapeutic area - Gastrointestinal

omeprazole - generic
pantoprazole - generic
Nexium packet for suspension

Capsule formulation
Dexilant (dexlansoprazole)
Nexium (esomeprazole)
Prilosec brand (omeprazole)
Prevacid (lansoprazole)
Protonix (pantoprazole)
lansoprazole – generic
omeprazole/bicarbonate generic
Zegerid (legend)(omeprazole/bicarbonate)

Other dosage forms
Prevacid Solutab
Lansoprazole solutab
Prilosec packet for suspension

Prilosec OTC excluded from coverage.
Prevacid OTC is excluded from coverage.
Zegerid OTC is excluded from coverage


Nonpreferred drugs- capsule formulation (Excludes Nexium)

  • The recipient has failed trials of omeprazole and pantoprazole due to lack of efficacy or presence of significant side-effects when dosed at the same frequency (e.g., QD, BID) as the requested drug. Trials should be 2 weeks in duration

Other dosage forms including Prevacid Solutab, lansoprazole solutab, or Prilosec packet

  • Patient or patient caregiver cannot open a capsule of a preferred agent and sprinkle the contents into 1/4 cup of apple, tomato or orange juice, or onto a tablespoon of applesauce, Ensure® pudding, cottage cheese, yogurt, or strained pears without crushing or chewing the capsules or the granules OR
  • Patient is being administered the proton pump inhibitor by G tube and has failed a trial of esomeprazole suspension


MHCP Provider Call Center 651-431-2700 or 800-366-5411

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