Limited Use Note(s)

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LANSOPRAZOLE & CLARITHROMYCIN & AMOXICILLIN30mg & 500mg & 500mg Tab/Cap Pk
Reason For Use CodeClinical Criteria
306For the treatment of H. pylori-positive peptic ulcers where H. pylori is documented, by serology, breath test or endoscopy, for a course of up to 14 days. Maximum duration: 14 days.
LU Authorization Period: 1 year
307For the retreatment of H. pylori-positive peptic ulcers where H. pylori recurrence or persistence is documented, by breath test or endoscopy, for a course of up to 14 days. Maximum duration: 14 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.
LU Authorization Period: 1 year