Zegerid — CareFirst (Caremark)

Preferred products

• generic proton pump inhibitors

Initial criteria

• The patient has experienced an inadequate treatment response, intolerance, or a contraindication to THREE generic proton pump inhibitors
• The request is for Zegerid (omeprazole/sodium bicarbonate) being prescribed for ANY of the following: Gastroesophageal reflux disease (GERD), Duodenal ulcer, Gastric ulcer, Short-term treatment of erosive esophagitis, Maintenance of healing of erosive esophagitis
• OR the request is for Konvomep (omeprazole/sodium bicarbonate) being prescribed for the short-term treatment of gastric ulcer

Approval duration

Konvomep: 3 months; Zegerid (GERD, Duodenal ulcer, Gastric ulcer, Short-term treatment of erosive esophagitis): 3 months; Zegerid (Maintenance healing of erosive esophagitis): 12 months