Limited coverage criteria (PPIs) – pantoprazole magnesium

Last updated on March 27, 2025

Special Authority requests can now be submitted online. It's simple and quick!

This drug is eligible for automatic approval when patient meets criteria and the request is submitted by eForms.

Generic name		pantoprazole magnesium
Strength & form		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, or connective tissue disease, e.g., lupus, scleroderma, CREST¹	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

OR

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

Indefinite

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

¹CREST 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 request form(s)

Log in to eForms
HLTH 5350 – Proton Pump Inhibitors (PDF, 516KB)

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