Limited Use Note(s)

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LANSOPRAZOLE & CLARITHROMYCIN & AMOXICILLIN30mg & 500mg & 500mg Tab/Cap Pk
Reason For Use CodeClinical Criteria
306a) For the treatment of H. pylori-positive peptic ulcers where H. pylori is documented, by serology, breath test or endoscopy, for a one week course. Maximum duration: 7 days.
LU Authorization Period: 1 year
307b) For the retreatment of H. pylori-positive peptic ulcers where H. pylori recurrence or persistence is documented, by breath test or endoscopy, for a one week course. Maximum duration: 7 days (after a four-week period has elapsed since the end of the previous treatment)
Retreatment decisions should be based upon positive symptoms and positive endoscopy or positive urea breath test. Retreatment should not be based on a positive serology test, as serology tests may remain positive indefinitely. An alternative antibiotic regimen is recommended when initial therapy fails due to concerns of antimicrobial resistance.
NETWORK NOTE: Network will limit supply to 7 days. Network will verify that retreatments are reimbursed only after a four-week period has elapsed since the end of the previous treatment.
LU Authorization Period: 1 year