Medicare AdvantagePrior AuthMedium impact
Omeprazole/Sodium Bicarbonate Products (Revised)
Humana·Gastroenterology, Critical Care, Internal Medicine·Medicare Advantage
Effective date
Dec 17, 2025
We identified it
Jun 25, 2026
Summary
This is a REVISED step therapy policy for Omeprazole/Sodium Bicarbonate products (Zegerid, Konvomep) effective January 1, 2017, with a revision date of December 17, 2025. The policy establishes prior authorization requirements: for erosive esophagitis and ulcer indications, members must have previous treatment with or intolerance to BOTH omeprazole AND pantoprazole; for GI bleeding prevention in critically ill patients, prior treatment with or intolerance to omeprazole is required. Approval is granted for the plan year duration initially and renewal plan year duration for continuation.
Action Required
By December 17, 2025: Billing and prior authorization teams must implement this step therapy policy in their authorization workflow for Medicare Advantage members requesting omeprazole/sodium bicarbonate products (Zegerid oral packets, generic omeprazole-sodium bicarbonate oral packets, Konvomep oral suspension). For ulcer and erosive esophagitis claims, verify documentation of previous treatment with or intolerance to BOTH omeprazole AND pantoprazole before approving coverage. For critically ill patient GI bleeding prevention claims, verify documentation of previous treatment with or intolerance to omeprazole only. Update authorization templates and clinical review workflows to capture these specific step therapy requirements. Providers must be notified of these step therapy criteria so they can include appropriate clinical documentation with authorization requests. Claims submitted without evidence of meeting these criteria will require denial or request for additional clinical information.