Limited coverage criteria – pantoprazole sodium
Last updated on July 9, 2026
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Generic name |
pantoprazole sodium |
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|---|---|---|
Strength & form |
40 mg tablet |
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Special Authority criteria
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Approval period |
|---|---|
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For gastroesophageal reflux disease (GERD), reflux esophagitis, duodenal ulcer, or gastric ulcer, when patient has experienced treatment failure of reasonable trials2 of, or intolerance to, rabeprazole AND pantoprazole magnesium |
Indefinite |
| For Barrett's esophagus, Zollinger-Ellison syndrome, connective tissue disease, e.g., lupus, scleroderma, CREST1, when patient has experienced treatment failure of reasonable trials2 of, or intolerance to, rabeprazole AND pantoprazole magnesium | Indefinite |
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For eradication of Helicobacter pylori as part of triple therapy, when patient has experienced treatment failure of reasonable trials2 of, or intolerance to, rabeprazole AND pantoprazole magnesium |
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