Proton pump inhibitors (PPIs) – pantoprazole magnesium
Last updated on January 22, 2024
|
Generic name |
pantoprazole magnesium |
|
|---|---|---|
|
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, or connective tissue disease, e.g., lupus, scleroderma, CREST |
Indefinite |
|
OR |
|
|
3. For eradication of Helicobacter pylori as part of triple therapy. |
Maximum 14 days |
Practitioner exemptions
Practitioners in the following specialty are not required to submit a Special Authority request for coverage:
- Gastroenterologists
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.