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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:  Erosive esophagitis  Gastroesophageal reflux disease (GERD)  Pathologic gastrointestinal (GI) hypersecretory conditions including Zollinger-Ellison Syndrome  protonix with food can protonix get you high protonix dosing instructions protonix drug interactions 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 . , one tablet in the morning and two tablets at night, one to two tablets at  Requested strength/dose is not commercially available  There is a medically protonix classification protonix oral suspension protonix prescribing information is protonix a necessary justification why the patient cannot use a higher commercially available strength to achieve the same dosage and remain within the same dosing frequency .

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