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 |
Practitioners in the following specialty are not required to submit a Special Authority request for coverage: