Limited coverage drugs – rabeprazole

Generic name		rabeprazole
Strength		10 mg, 20 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	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.

Special Authority requests

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• HLTH 5350 - Proton Pump Inhibitors (PPIs) (PDF, 127KB)