Proton Pump Inhibitors – Esomeprazole
|20 mg, 40 mg|
Special Authority Criteria
|1. For gastroesophageal reflux disease (GERD), reflux esophagitis, duodenal ulcer, or gastric ulcer.||Indefinite|
|2. For Barrett's esophagus, Zollinger-Ellison syndrome, connective tissue disease, e.g., lupus, scleroderma, CREST.||Indefinite|
|3. For eradication of Helicobacter pylori, as part of triple therapy.||Maximum 14 days|
|Failure of reasonable trials of, or intolerance to, rabeprazole AND pantoprazole magnesium.|
- No practitioner exemptions.
- 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.