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generic pantoprazole granules for oral suspension — Medica

acid-related gastrointestinal diseases (e.g., gastroesophageal reflux disease, duodenal or gastric ulcers, Zollinger-Ellison syndrome, Helicobacter pylori infection)

Preferred products

  • generic esomeprazole delayed-release capsules
  • generic lansoprazole delayed-release capsules
  • generic omeprazole delayed-release capsules
  • generic omeprazole delayed-release tablets
  • generic pantoprazole delayed-release tablets
  • generic rabeprazole delayed-release tablets
  • Nexium 24HR OTC

Initial criteria

  • If patient is age < 1 year, approve generic esomeprazole delayed-release granules for oral suspension or Prilosec delayed-release granules for oral suspension.
  • If patient is age < 11 years and requires administration via feeding tube, approve generic esomeprazole delayed-release granules for oral suspension or Prilosec delayed-release granules for oral suspension.
  • If patient requires administration via a feeding tube AND has tried a Step 1 Product under the supervision of a physician, approve a Step 2 Product (except Konvomep, Zegerid, Zegerid OTC, and generic omeprazole/sodium bicarbonate capsules).
  • If patient has tried a Step 1 Product under the supervision of a physician, approve a Step 2 Product (except Konvomep, Zegerid, Zegerid OTC, and generic omeprazole/sodium bicarbonate capsules). A trial of a generic OTC proton pump inhibitor counts if used for ≥ 14 days and OTC PPIs are a covered benefit.
  • If requested product is Konvomep, Zegerid, Zegerid OTC, or generic omeprazole/sodium bicarbonate capsules (Rx or OTC), approve if patient has tried five generic proton pump inhibitors (esomeprazole, lansoprazole, omeprazole, pantoprazole, AND rabeprazole). A trial of a generic OTC PPI qualifies if used for ≥ 14 days and OTC PPIs are covered.

Approval duration

1 year