Harvard Pilgrim now covers Nexium 24HR, the over-the-counter formulation of Nexium, at Tier 1 on all formularies. For dates of service beginning June 1, 2016, prior authorization will be required for other formulations of Nexium as follows:
- Premium formulary — Prior authorization is required for prescription brand-name Nexium and its generic equivalent esomeprazole.
- Value formulary — Prior authorization is required for esomeprazole (brand name Nexium is not covered on the Value formulary).
This prior authorization requirement will apply to members new to treatment, as well as those currently being prescribed these proton-pump inhibitors (PPIs) to treat their gastroesophageal reflux (GERD). Coverage for prescription Nexium in powder packet form will not be affected by this change; it will continue to be covered without prior authorization.
Harvard Pilgrim will cover Nexium 24HR, available in a 20mg-strength capsule, when it is prescribed by the provider and dispensed at the patient’s pharmacy.
If any of your Harvard Pilgrim patients are currently taking prescription Nexium and esomeprazole for GERD, please consider moving them to the over-the-counter version since this will allow them to incur lower out-of-pocket costs.
Harvard Pilgrim’s Nexium Clinical Review Criteria detail the requirements that must be met in order to obtain prior authorization. To request prior authorization, please complete the Nexium Medication Request Form and fax it to MedImpact Healthcare Systems at 888-807-6643. For more information, refer to the Pharmacy section of Harvard Pilgrim's provider website.