bismuth subcitrate potassium; metronidazole; tetracycline hydrochloride — Highmark
Helicobacter pylori infection
Preferred products
- bismuth subcitrate potassium; metronidazole; tetracycline hydrochloride (generic)
Initial criteria
- age ≥ 18 years
- Diagnosis of H. pylori infection (ICD-10: B96.81) confirmed by invasive techniques (e.g., endoscopic) OR non-invasive techniques (e.g., urea breath test, stool antigen assay test)
- Member has previously been treated with all of the following components of a first-line treatment regimen and post-treatment testing has confirmed treatment failure to eradicate H. pylori infection: lansoprazole OR omeprazole, amoxicillin OR metronidazole, clarithromycin OR member has a clarithromycin allergy or prior exposure to macrolide therapy
- Concomitant use of omeprazole 20 mg twice daily (after the morning and evening meals) with Pylera therapy
- If the request is for brand Pylera, member has experienced therapeutic failure or intolerance to generic bismuth subcitrate potassium; metronidazole; tetracycline hydrochloride capsules
Approval duration
14 days