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Limited Coverage Drugs - Special Authority Criteria
| Generic Name / Strength / Form |
| pantoprazole sodium 40mg |
| Criteria |
Approval Period |
| 1. For gastroesophageal reflux disease (GERD), reflux esophagitis, duodenal ulcer, or gastric ulcer after documented failure or intolerance to adequate doses of ranitidine or cimetidine or other H2 blocker
PLUS failure or intolerance to rabeprazole AND pantoprazole magnesium. | Indefinite |
OR |
2. For Barrett's esophagus, Zollinger-Ellison syndrome, connective tissue disease, e.g., lupus, scleroderma, CREST.
PLUS failure or intolerance to rabeprazole AND pantoprazole magnesium. | Indefinite |
OR |
3. For eradication of Helicobacter pylori, as part of triple therapy
PLUS
failure or intolerance to rabeprazole AND pantoprazole magnesium. |
Maximum 14 days |
Practitioner
Exemptions
Special Notes
- Exceptions considered regarding rabeprazole and pantoprazole magnesium trials for identified pediatric and pregnant/lactating patients, and for those with uncommon gastrointestinal conditions.
- CREST is an acronym for the five main features of the limited form of scleroderma: Calcinosis, Raynaud’s disease, Esophageal dysmotility, Sclerodactyly, and Telangiectasia.
- “Failure or intolerance to rabeprazole AND pantoprazole magnesium” is defined as documented failure or intolerance after an 8-week trial of the first option at adequate doses, followed by documented failure or intolerance after a 4-week trial of the second option at adequate doses.
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