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202106-139030

2021

CVS Caremark

Self-Funded

Digestive System/ Gastrointestinal

Pharmacy/ Prescription Drugs

Formulary Exception

Upheld

Case Summary

Diagnosis: Digestive System
Treatment: Pharmacy/prescription drug
The insurer denied Esomeprazole Capsules DR. The health plan's determination is upheld.

The patient is a female with gastroesophageal reflux disease (GERD). She presented with good control of reflux on pantoprazole 20 milligrams (mg) daily.

Esophagogastroduodenoscopy for the indication of dyspepsia (despite proton pump inhibitor) showed no evidence of reflux, and showed gastric polyps and antral gastritis; biopsies showed mild reflux-associated changes in the esophagus, mild chronic gastric inflammation, and proton pump inhibitor-associated gastric changes.

A second Esophagogastroduodenoscopy for the indication of dyspepsia showed no evidence of uncontrolled reflux disease, and gastric polyps; biopsies showed reflux-associated changes in the esophagus, minimal chronic nonspecific gastritis, and fundic gland polyps.

Under review is the use of Esomeprazole Capsules.

The request for esomeprazole is not supported over the formulary proton pump inhibitors (lansoprazole, omeprazole, Dexilant), as these would not be expected to have lower efficacy or different adverse effects from esomeprazole.

Proton pump inhibitor therapy is recommended by American College of Gastroenterology guidelines for gastroesophageal reflux disease. The patient is documented to have failed pantoprazole. Comparison of multiple proton pump inhibitors (PPIs), including omeprazole, esomeprazole, pantoprazole, lansoprazole, and rabeprazole has found no difference in control and healing of GERD between them, and superiority of Dexilant to esomeprazole. In this case, there is no documented reason to use esomeprazole over the formulary alternatives that have not been attempted. A formulary exception is not indicated.

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