Product Details

Jamp-Pantoprazole

Pantoprazole Sodium
40 mg
Enteric Coated Tablet


DIN/PIN/NPN

02357054

Manufacturer

Jamp Pharma Corporation

Formulary Listing Date

2014-02-27  

Unit Price

0.2016

Amount MOH Pays

0.2016

Coverage Status

Limited Use Product Chronic-Use Medication

ODB Formulary Therapeutic Classification

Therapeutic Note

NO

ATC Code

A02BC02

Interchangeable Products

DIN/ PIN/ NPN Brand name Unit Price Amount MOH pays
02285487 Teva-Pantoprazole 0.2016 0.2016
02301083 Sandoz Pantoprazole 0.2016 0.2016
02305046 Ran-Pantoprazole 0.2016 0.2016
02307871 PMS-Pantoprazole 0.2016 0.2016
02428180 Pantoprazole-40 0.2016 0.2016
02370808 Pantoprazole 0.2016 0.2016
02229453 Pantoloc 2.0803 0.2016
02471825 NRA-Pantoprazole 0.2016 0.2016
02467372 M-Pantoprazole 0.2016 0.2016
02417448 Mint-Pantoprazole 0.2016 0.2016
02416565 Mar-Pantoprazole 0.2016 0.2016
02357054 Jamp-Pantoprazole 0.2016 0.2016
02392623 Jamp Pantoprazole Sodium 0.2016 0.2016
02300486 Co Pantoprazole 0.2016 0.2016
02415208 Auro-Pantoprazole 0.2016 0.2016
02292920 Apo-Pantoprazole 0.2016 0.2016
02481588 AG-Pantoprazole Sodium 0.2016 0.2016
 

LU Clinical Criteria

LU Code Auth. Period Clinical Criteria
293 1 year

Gastroesophageal Reflux Disease (GERD)

For the treatment of erosive GERD or upper GI malignancy; OR

For the treatment of non-erosive GERD after failure of H2-receptor antagonist therapy.

Patients with GERD should be reassessed within 6 months after initial treatment with a PPI.  The reassessment could include confirmation of need for PPI with endoscopy, a trial of PPI withdrawal, or step-down therapy to H2-receptor antagonist therapy.

Note: There is a lack of published evidence to support double-dose PPI therapy in this setting.

295 1 year

H. pylori-positive Peptic Ulcers

For the treatment of H. pylori-positive peptic ulcers where H. pylori is documented, by serology, urea breath test or endoscopy, for a course of up to 14 days in combination with antimicrobial therapy. Retreatment of H. pylori-positive peptic ulcers must be documented by persistent H. pylori infection on urea breath test or endoscopy.

Maximum duration: 14 days (for retreatment, a four-week period must elapse since the end of the previous treatment).

297 1 year

Confirmed Peptic Ulcers or NSAID-induced Ulcer Prophylaxis:

For the treatment of confirmed peptic ulcers and NSAID-induced ulcers; OR

For the prophylaxis of NSAID-induced ulcers for patients at increased risk of GI bleeding.

Note: There is a lack of published evidence to support double-dose PPI therapy in this setting.

401 1 year

Other Gastrointestinal Disorders:

For the treatment of gastroduodenal Crohn's disease, short-gut syndrome, scleroderma, or pancreatitis.

Note: There is a lack of published evidence to support double-dose PPI therapy in these settings.

402 1 year

Severe Conditions:

For the treatment of severe esophagitis, Zollinger-Ellison syndrome, esophageal stricture, persistent symptoms of GERD or persistent erosive esophagitis, or upon hospital discharge following a gastrointestinal bleed.

For patients receiving double-dose therapy, the need to continue treatment at higher doses should be reassessed after eight weeks. For re-treatment at higher doses, a four-week period should have elapsed from the end of the previous treatment. Reassessment could include a procedural assessment of the condition or step-down therapy to lower-dose proton pump inhibitor (PPI) therapy.

 

EAP Criteria

NO

Product Monograph

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