Limited Use Note(s)

OMEPRAZOLE MAGNESIUM20mg

Reason For Use Code	Clinical Criteria
295	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).
	LU Authorization Period: 1 year

Reason For Use Code

Clinical Criteria

295

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).

LU Authorization Period: 1 year

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