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July 1, 2005
TO:                 Prescribing Providers, Pharmacists, Pharmacies, Hospitals, and Long-Term Care Facilities
FROM:           Randy May, Deputy Administrator
SUBJECT:     Replacing information in IR 2005-11 for this drug class only:  NEW PRIOR AUTHORIZATION CRITERIA FOR PROTON PUMP INHIBITOR DRUG CLASS
Drug/Drug Class:
Implementation Date:
Effective for dates of service on or after August 1, 2005

Idaho Medicaid is adopting therapeutic criteria for the Proton Pump Inhibitor therapeutic drug class as part of the Enhanced Prior Authorization Program. Beginning August 1, 2005, all agents for the Proton Pump Inhibitor drug class will be subject to the following therapeutic criteria:
Proton pump inhibitors are authorized for eligible clients that meet at least one of the following criteria:
1.       Have a diagnosis of Zollinger-Ellison Syndrome, mastocytosis, esophageal reflux disease and/or esophagitis, or acute peptic ulcer treatment in H. pylori positive patients.  
2.       Have a history of or current diagnosis of gastrointestinal complications including gastrointestinal bleeding, perforation, complicated peptic ulcer disease, gastrointestinal organ cancer or concurrent pancreatic enzyme co-therapy in Cystic Fibrosis patients.
3.       Currently using a non-COX-2 NSAID co-therapy with a peptic ulcer disease or gastrointestinal bleed history or concurrent use of warfarin or corticosteroids.
4.       Client is 18 years of age or younger.  
Preferred Agents for the Proton Pump Inhibitor drug class are unchanged. The preferred agents are:
Preferred Agent(s)*
Non-preferred Agents*
·         Nexium®
·         Prevacid®
·         Prilosec OTC®
·         Aciphex®
·         Omeprazole
·         Prilosec®
·         Protonix®
* Use of any Proton Pump Inhibitor must meet therapeutic and preferred agent prior authorization criteria.
Questions regarding the Prior Authorization program may be referred to Medicaid Pharmacy at (208) 364-1829.

A current listing of all the preferred agents by drug class and prior authorization criteria is also available online at
This Information Release does not replace information in your Idaho Medicaid Handbook.