Limited coverage criteria (PPIs) – pantoprazole sodium
Last updated on March 20, 2025
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Generic name |
pantoprazole sodium |
|
|---|---|---|
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, 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 |
14 days |
Practitioner exemptions
- No practitioner exemptions
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
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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