Prior Approval Information Specific to Barrett’s Esophagitis, Zollinger-Ellison Syndrome, and Erosive Esophagitis

Prevacid is the preferred PPI. When requesting a prior approval for a prescription PPI due to Barrett's Esophagitis, Zollinger-Ellison Syndrome or Erosive Esophagitis, please complete all sections of the standard prior approval form the Request for Prior Approval Form HFS 3082 (pdf).

The information below is also required:

Zollinger-Ellison Syndrome

Diagnosis

Barrett's Esophagitis

Diagnosis

Copy of most recent endoscopy results (within last 18 months)

Erosive Esophagitis

Diagnosis

Copy of most recent endoscopy results (within last 18 months)

Other

Diagnosis, along with any other pertinent information to substantiate the request.