Proton Pump Inhibitors – Omeprazole

Generic Name

omeprazole

 Strength

20 mg
Form tablet/capsule

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

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.
  • Reasonable trials of rabeprazole and pantoprazole magnesium will be considered a trial at usual adult doses for at least 4 weeks for each of the two reference PPIs.

Forms