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Reason for Use code 293 Gastroesophageal Reflux Disease (GERD) For the treatment of erosive GERD or upper GI malignancy; OR For the treatment of non-erosive GERD after failure of H2-receptor antagonist therapy. Patients with GERD should be reassessed within 6 months after initial treatment with a PPI. The reassessment could include confirmation of need for PPI with endoscopy, a trial of PPI withdrawal, or step-down therapy to H2-receptor antagonist therapy. Note: There is a lack of published evidence to support double-dose PPI therapy in this setting. Coverage limit: LU Authorization Period: 1 year Reason for Use code 295 H. pylori-positive Peptic Ulcers For the treatment of H. pylori-positive peptic ulcers where H. pylori is documented, by serology, urea breath test or endoscopy, for a course of up to 14 days in combination with antimicrobial therapy. Retreatment of H. pylori-positive peptic ulcers must be documented by persistent H. pylori infection on urea breath test or endoscopy. Maximum duration: 14 days (for retreatment, a four-week period must elapse since the end of the previous treatment). Coverage limit: LU Authorization Period: 1 year Reason for Use code 297 Confirmed Peptic Ulcers or NSAID-induced Ulcer Prophylaxis: For the treatment of confirmed peptic ulcers and NSAID-induced ulcers; OR For the prophylaxis of NSAID-induced ulcers for patients at increased risk of GI bleeding. Note: There is a lack of published evidence to support double-dose PPI therapy in this setting. Coverage limit: LU Authorization Period: 1 year Reason for Use code 401 Other Gastrointestinal Disorders: For the treatment of gastroduodenal Crohns disease, short-gut syndrome, scleroderma, or pancreatitis. Note: There is a lack of published evidence to support double-dose PPI therapy in these settings. Coverage limit: LU Authorization Period: 1 year Reason for Use code 402 Severe Conditions: For the treatment of severe esophagitis, Zollinger-Ellison syndrome, esophageal stricture, persistent symptoms of GERD or persistent erosive esophagitis, or upon hospital discharge following a gastrointestinal bleed. For patients receiving double-dose therapy, the need to continue treatment at higher doses should be reassessed after eight weeks. For re-treatment at higher doses, a four-week period should have elapsed from the end of the previous treatment. Reassessment could include a procedural assessment of the condition or step-down therapy to lower-dose proton pump inhibitor (PPI) therapy. Coverage limit: LU Authorization Period: 1 year

Lowest DBP recovery rule under medically necessary no-substitution claims: 6.2 Medically Necessary "No Substitution" Claims The Side Effect Reporting Form will not have to be renewed. However, the pharmacy must maintain a copy of the prescription that contains a direction that there be no substitution and the required Health Canada Side Effect Reporting Form (completed and signed by the prescriber). The prescriber must write “No Substitution” or “No Sub” on renewal or subsequent new written prescriptions, and indicate “No Substitution” on subsequent new oral prescriptions. The dispenser will be reimbursed the DBP plus a mark-up and the lesser of the posted usual and customary fee or the ODB dispensing fee minus the applicable ODB co-payment amount. Where a completed Side Effect Reporting Form is not available at the pharmacy during an inspection, the difference between the cost of the higher-cost product and the lowest DBP listed for the interchangeable category will be recovered. (ontario.ca, Revision #17; 2026-08-03 ↗) 6.2 Medically Necessary "No Substitution" Claims The Ministry will provide reimbursement of a higher-cost interchangeable product in medically necessary circumstances where a patient has experienced a significant adverse reaction with two (2) lower-cost interchangeable drug products, where available. When a prescriber identifies a patient for which it is medically necessary that a higher cost interchangeable product be provided, the prescriber must: • Complete, sign and forward to the pharmacist a copy of the Health Canada side effect reporting form for each lower-cost interchangeable drug product trialed (Side Effect Reporting Form[s]); and • Write “No Substitution” or “No Sub” on a written prescription or indicate “No Substitution” to the pharmacist in the case of a verbal prescription. The prescriber should keep a copy of the completed form in the patient’s record for future use and reference. In the case of a written prescription, when the pharmacist or dispensing physician receives a prescription with the written notation “No Substitution” or “No Sub”, reimbursement will be provided for the higher-cost interchangeable product only if the prescription is accompanied by a completed Health Canada Side Effect Reporting Form for each of the lower-cost interchangeable drug products trialed. This form must be completely filled out noting the details of the adverse reaction and signed by the prescriber. In the case of a verbal prescription, the prescriber must satisfy the operator of the pharmacy or dispensing physician that a completed Health Canada Side Effect Reporting Form for each of the lower-cost interchangeable drug products trialed has been completed and signed by the prescriber. A written record of this verbal prescription and the completed Health Canada Side Effect Reporting Form must be received by the pharmacy prior to claim submission. Upon receipt, the pharmacist must: • Fax, submit online or mail the completed and signed form to Health Canada’s Canada Vigilance Program; and • Retain his or her copy of the completed and signed Side Effect Reporting Form. (ontario.ca, Revision #17; 2026-08-03 ↗)

Jamp-Pantoprazole · DIN 02357054 Manufacturer: Jamp Pharma Corporation; listing date 2014-02-27 Health Canada: Marketed since 2020-06-15 · brand JAMP-PANTOPRAZOLE · ATC A02BC02 PANTOPRAZOLE · form Tablet (delayed-release) · route Oral · ingredients PANTOPRAZOLE (PANTOPRAZOLE SODIUM) 40 MG · company Jamp pharma corporation · schedule Prescription

DIN 02357054: Jamp-Pantoprazole Raw flags: chronicUseMed=Y, sec12=Y, sec3=Y Item: 564000080; group id 694; item number 1716; lccId 00106; manufacturer id JPC Source form: Ent Tab; strength: 40mg Recorded listing: Limited Use: paid only with a Reason for Use code and the criteria below; chronic-use medication (100-day supply rule, dispensing-fee limit) Source prices (unrounded): $0.2016; ministry $0.2016 Source: ODB odb-formulary-ed43-extract-2026-08-26.xml extract_date=2026-08-26 DIN=02357054 Health Canada DPD extract of Sep 2, 2026 (Open Government Licence – Canada) · https://health-products.canada.ca/dpd-bdpp/info?lang=eng&code=84215

Interchangeable products

AG-Pantoprazole Sodium · DIN 02481588 · $0.2016 Apo-Pantoprazole · DIN 02292920 · $0.2016 Auro-Pantoprazole · DIN 02415208 · $0.2016 Bio-Pantoprazole · DIN 02445867 · $0.2016 Co Pantoprazole · DIN 02300486 · $0.2016 Jamp Pantoprazole Sodium · DIN 02392623 · $0.2016 M-Pantoprazole · DIN 02467372 · $0.2016 Mar-Pantoprazole · DIN 02416565 · $0.2016 Mint-Pantoprazole · DIN 02417448 · $0.2016 NRA-Pantoprazole · DIN 02471825 · $0.2016 PMS-Pantoprazole · DIN 02307871 · $0.2016 Pantoloc · DIN 02229453 · $0.2016 Pantoprazole · DIN 02370808 · $0.2016 Pantoprazole · DIN 02428180 · $0.2016 Pantoprazole · DIN 02431327 · $0.2016 Pantoprazole · DIN 02547368 · $0.2016 Ran-Pantoprazole · DIN 02305046 · $0.2016 Sandoz Pantoprazole · DIN 02301083 · $0.2016 Teva-Pantoprazole · DIN 02285487 · $0.2016

Shortage status: not checked (no credentials)