Proton Pump Inhibitors – Pantoprazole Sodium

Generic Name

pantoprazole sodium (Na)
Strength

40 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.

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)