Proton Pump Inhibitors – Esomeprazole

Generic Name



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
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.

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)