Maximum Daily Dose/ interval - Aetna



Maximum Daily Dose with Precertification

|Drug |Zollinger-Ellison |Barrett’s esophagus |H-Pylori |Refractory GERD |

| |Syndrome | | | |

|Nexium |240 mg |80 mg |80 mg |80 mg |

|Prilosec |Up to 180 packets in |Up to 120 packets in |Up to 120 packets in 30 |Up to 120 packets in 30 |

| |30 days |30 days |days |days |

|lansoprazole |180 mg |60 mg |60 mg |30 mg |

|Prevacid | | | | |

omeprazole/sodium bicarbonate,

Zegerid |80 mg |40mg |40 mg |40 mg | |

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