Limited coverage criteria – lansoprazole
Last updated on July 9, 2026
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Generic name |
lansoprazole |
|
|---|---|---|
Strength & form |
15 mg, 30 mg capsule and rapid-dissolve tablet |
|
Special Authority criteria |
Approval period |
|---|---|
|
For the treatment of gastroesophageal reflux disease (GERD), reflux esophagitis, duodenal ulcer, or gastric ulcer when patient has experienced treatment failure following reasonable trials2 of, or intolerance to, rabeprazole AND pantoprazole magnesium. |
Indefinite |
|
For the treatment of Barrett's esophagus, Zollinger-Ellison syndrome, or connective tissue disease, (e.g., lupus, scleroderma, CREST1) when patient has experienced treatment failure following reasonable trials2 of, or intolerance to, rabeprazole AND pantoprazole magnesium. |
Indefinite |
|
For eradication of Helicobacter pylori as part of triple therapy when patient has experienced treatment failure following reasonable trials2 of, or intolerance to, rabeprazole AND pantoprazole magnesium. |
Maximum 14 days |
Practitioner exemptions
- No practitioner exemptions
Special notes
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1CREST is an acronym for the five main features of the limited form of scleroderma: Calcinosis, Raynaud’s disease, esophageal dysmotility, sclerodactyly, and telangiectasia
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2A 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