Proton Pump Inhibitors – Lansoprazole

Generic Name

lansoprazole

Strength

15 mg, 30 mg

Form

capsule​ and rapid dissolve 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.

14 days

PLUS

Failure of reasonable trials of, or intolerance to, rabeprazole AND pantoprazole magnesium. 

Practitioner Exemptions

  • No practitioner exemptions.

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.

  • A reasonable trial of rabeprazole and pantoprazole magnesium is considered a trial at usual adult doses for at least 4 weeks each of rabeprazole and pantoprazole magnesium.

Special Authority Request Form(s)