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Please note: All information below is required how often can you take protonix can i drink alcohol while taking protonix when should i take to process this request .
Mon-Fri: 5am to protonix 10pm Pacific / Sat: 6am to 3pm Pacific Protonix® (pantoprazole) Prior Authorization Request Form DO NOT COPY FOR FUTURE USE .
, one tablet in the protonix morning and two tablets at night, one to two tablets at  Requested strength/dose is not commercially available  There is a medically necessary justification why the patient cannot use a higher commercially available strength to achieve the same dosage and remain within the same dosing frequency . FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED Member Information (required) Provider Information (required) Office Street Address: Medication Information (required) Medication Name:  Check if requesting brand  Check if request is for continuation of therapy Directions for Use: Clinical Information (required) Select the diagnosis below: how long should you take protonix when should i take protonix side effects protonix 40 mg cost of  Erosive esophagitis  Gastroesophageal reflux disease (GERD)  Pathologic gastrointestinal (GI) hypersecretory conditions including Zollinger-Ellison Syndrome  Other diagnosis: ______________________________ ICD-10 Code(s): ______________________________ For brand Protonix requests, select the medications the patient has a failure, contraindication, or intolerance to:  Nexium granule  Esomeprazole magnesium  Omeprazole capsule  Esomeprazole sodium  Omeprazole-sodium bicarbonate  Esomeprazole strontium  Lansoprazole capsule  Prevacid Solutab  Lansoprazole orally disintegrating tablet (ODT)  Nexium capsule Quantity limit requests: What is the quantity requested per DAY? ______ What is the reason for exceeding the plan limitations?  Titration or loading-dose purposes  Patient is on a dose-alternating schedule (e .

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