Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
rabeprazole 10 mg, 20 mg

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. Indefinite

OR

2. For Barrett's esophagus, Zollinger-Ellison syndrome, connective tissue disease, e.g., lupus, scleroderma, CREST. Indefinite

OR

3. For eradication of Helicobacter pylori, as part of triple therapy. Maximum 14 days

Practitioner Exemptions

  • Gastroenterologists

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.
  • The usual recommended dose is 20 mg daily.

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