Proton Pump Inhibitors – Esomeprazole
Generic Name |
esomeprazole |
Strength |
20 mg, 40 mg |
Form | tablet |
Special Authority 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.
- 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.