Limited coverage criteria – esomeprazole

Last updated on March 17, 2025

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Generic name	esomeprazole
Strength & form	20 mg, 40 mg tablet

Special Authority criteria	Approval period
For gastroesophageal reflux disease (GERD), reflux esophagitis, duodenal ulcer, or gastric ulcer OR For Barrett's esophagus, Zollinger-Ellison syndrome, connective tissue disease, e.g., lupus, scleroderma, CREST	Indefinite
For eradication of Helicobacter pylori, as part of triple therapy	Maximum 14 days

Special Authority criteria

Approval period

For gastroesophageal reflux disease (GERD), reflux esophagitis, duodenal ulcer, or gastric ulcer

For Barrett's esophagus, Zollinger-Ellison syndrome, connective tissue disease, e.g., lupus, scleroderma, CREST

Indefinite

For eradication of Helicobacter pylori, as part of triple therapy

Maximum 14 days

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Failure of reasonable trials of, or intolerance to, rabeprazole AND pantoprazole magnesium

Practitioner exemptions

None

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)

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HLTH 5350 - Proton Pump Inhibitors (PPIs) request (PDF, 516KB)

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