Maximum Daily Dose with Precertification

Drug / Zollinger-Ellison Syndrome / Barrett’s esophagus / H-Pylori / Refractory GERD
AcipHex / 60 mg / 60 mg / 40 mg / 40 mg
Dexilant / 180 mg / 90 mg / 60 mg / 60 mg
Nexium / 240 mg / 80 mg / 80 mg / 80 mg
omeprazole
Prilosec / 360 mg / 80 mg / 80 mg / 80 mg
Prilosec / Up to 180 packets in 30 days / Up to 120 packets in 30 days / Up to 120 packets in 30 days / Up to 120 packets in 30 days
lansoprazole
Prevacid / 180 mg / 60 mg / 60 mg / 30 mg
lansoprazole ODT
Prevacid Solutab / 180 mg / 60 mg / 60 mg / 30 mg
pantoprazole
Protonix / 240 mg / 80 mg / 80 mg / 40 mg
Zegerid / Up to 60 packets in 30 days / Up to 30 packets in 30 days / Up to 30 packets in 30 days / Up to 30 packets in 30 days
omeprazole/sodium bicarbonate,
Zegerid / 80 mg / 40mg / 40 mg / 40 mg