Limited coverage criteria – (PPIs) omeprazole

Last updated on March 24, 2025

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Generic name		omeprazole
Strength & form		20 mg tablet/capsule

Special Authority criteria	Approval period
For gastroesophageal reflux disease (GERD), reflux esophagitis, duodenal ulcer or gastric ulcer	Indefinite
For Barrett's esophagus, Zollinger-Ellison syndrome, connective tissue disease, e.g., lupus, scleroderma, CREST¹	Indefinite
For eradication of Helicobacter pylori as part of triple therapy AND Failure of reasonable trials² of, or intolerance to, rabeprazole AND pantoprazole magnesium	Maximum 14 days

Special Authority criteria

Approval period

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

Indefinite

For Barrett's esophagus, Zollinger-Ellison syndrome, connective tissue disease, e.g., lupus, scleroderma, CREST¹

Indefinite

For eradication of Helicobacter pylori as part of triple therapy

AND

Failure of reasonable trials² of, or intolerance to, rabeprazole AND pantoprazole magnesium

Maximum 14 days

Practitioner exemptions

None

Special notes

¹CREST is an acronym for the five main features of the limited form of scleroderma: calcinosis, Raynaud’s disease, esophageal dysmotility, sclerodactyly, and telangiectasia.
²Reasonable trials of rabeprazole and pantoprazole magnesium will be considered a trial at usual adult doses for at least 4 weeks for each of the two reference PPIs

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HLTH 5350 – Proton Pump Inhibitors (PDF, 516 KB)

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