Proton Pump Inhibitors – Rabeprazole

Generic Name

rabeprazole                                                                                                  

Strength

10 mg, 20 mg
Form tablet 
Criteria Approval Period

1. For gastroesophageal reflux disease (GERD), reflux esophagitis, duodenal ulcer, or gastric ulcer.

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

Practitioners in the following specialty are not required to submit a Special Authority request form for coverage:

  • Gastroenterologists

Special Notes

  • CREST is an acronym for the five main features of the limited form of scleroderma: Calcinosis, Raynaud’s disease, Esophageal dysmotility, Sclerodactyly, and Telangiectasia.

Special Authority Request Form(s)