Medicare coverage for Zegerid depends on which part of Medicare you have and whether your doctor prescribes it as medically necessary

Zegerid is a brand-name medication that combines omeprazole (a proton pump inhibitor) with sodium bicarbonate. It reduces stomach acid and is used to treat conditions like gastroesophageal reflux disease (GERD) and ulcers. Medicare Part D, which covers prescription drugs, may cover Zegerid, but coverage is not automatic — it depends on your specific plan and whether your doctor's reason for prescribing it meets your plan's requirements.

Medicare Part B does not cover Zegerid because it is an oral medication taken at home, not an injectable or infusion drug administered in a medical setting. If you receive Zegerid in a hospital or skilled nursing facility as part of your inpatient care, Medicare Part A may cover it as part of your stay, but you would not pay separately for the medication itself.

Key Takeaways

  • Medicare Part D plans cover Zegerid for most people, but your specific plan decides whether it is on the formulary (the list of covered drugs) and at what cost tier.
  • Your doctor may need to submit a prior authorization request to your Part D plan before you fill a Zegerid prescription, especially if a generic alternative is available.
  • Generic omeprazole is usually cheaper and more likely to be covered without restrictions than brand-name Zegerid, so ask your doctor whether the generic version would work for you.
  • You can check your plan's formulary on Medicare.gov or by calling your plan's customer service number to find out the exact cost and any restrictions before you fill the prescription.

How Medicare Part D covers Zegerid

Medicare Part D is the prescription drug benefit, and it covers most oral medications including Zegerid — but only if your plan includes it on its formulary. Each Part D plan creates its own formulary, which is the official list of drugs the plan will pay for. Some plans cover Zegerid with no restrictions, some require you to try a generic alternative first, and some do not cover it at all.

When a plan does cover Zegerid, you typically pay a copay or coinsurance amount at the pharmacy. The amount depends on which tier of the formulary Zegerid is placed on. Brand-name drugs usually sit on a higher tier than generics, which means you pay more out of pocket. In 2024, Part D copays for brand-name drugs range widely by plan, but many plans charge $35 to $75 per prescription for a brand-name medication.

Your plan's formulary can change from year to year, so coverage you had in one year may not explore the next. You can review your plan's current formulary on Medicare.gov by searching for your specific plan, or you can call your plan's customer service number — the number is on your insurance card.

Prior authorization and step therapy requirements

Many Medicare Part D plans require prior authorization before they will cover Zegerid. This means your doctor must contact your plan and explain why Zegerid is medically necessary for you before you can fill the prescription. The plan then decides whether to approve it.

Some plans also use step therapy, which means you must try a cheaper alternative drug first — usually generic omeprazole — and show that it did not work for you before the plan will cover Zegerid. Step therapy is common for brand-name proton pump inhibitors because generics are available and work the same way for most people.

If your plan requires prior authorization or step therapy, your doctor's office typically handles the request. However, you should ask your doctor's office to confirm they have submitted it and to tell you when you can expect an answer. Prior authorization decisions usually come back within a few business days, but sometimes take longer.

Generic omeprazole as a lower-cost alternative

Generic omeprazole is the active ingredient in Zegerid and is covered by virtually all Medicare Part D plans. It costs significantly less than brand-name Zegerid because it does not carry the brand name or the sodium bicarbonate formulation. For most people with GERD or ulcers, generic omeprazole works just as well as Zegerid.

If your plan does not cover Zegerid or places it on a high-cost tier, ask your doctor whether you can take generic omeprazole instead. Generic omeprazole is available as a capsule or tablet and is often available without prior authorization. Your out-of-pocket cost for generic omeprazole is typically much lower — many plans cover it with a $0 to $15 copay.

The main difference between Zegerid and generic omeprazole is that Zegerid contains sodium bicarbonate, which helps the medication work faster by raising stomach pH. For people who need rapid relief, this can matter. For routine GERD management, the difference is usually not significant enough to justify the higher cost.

Checking your plan's coverage before you fill a prescription

Before your doctor writes a Zegerid prescription, or before you fill one, check whether your specific Part D plan covers it. You can do this in three ways: use the Medicare Plan Finder tool on Medicare.gov, call your plan's customer service number, or ask your pharmacist to check your coverage when you bring the prescription in.

When you check, ask for the following information: Is Zegerid on the formulary? If yes, what tier is it on, and what is your copay or coinsurance? Does the plan require prior authorization? Does the plan require step therapy (trying generic omeprazole first)? Having these answers before you fill the prescription saves time and prevents surprises at the pharmacy.

If your plan does not cover Zegerid or the cost is very high, ask your pharmacist about the cash price for generic omeprazole. Sometimes the cash price for a generic is lower than your copay for a brand-name drug, especially if you have not yet met your deductible.

What to do if your plan denies coverage

If your Part D plan denies coverage for Zegerid or requires step therapy you believe is not appropriate for your situation, you have the right to appeal. Your doctor can submit a written appeal explaining why Zegerid is medically necessary for you and why generic omeprazole or other alternatives have not worked or are not suitable.

Appeals usually take 7 to 14 days for a standard review. If you need the medication urgently, you can request an expedited appeal, which must be decided within 72 hours. Your doctor's office can help you file the appeal, or you can contact your plan's member services department to ask how to submit one yourself.

If the appeal is denied, you can file a complaint with Medicare by calling 1-800-MEDICARE or visiting Medicare.gov. You can also ask your State Health Insurance information Program (SHIP) for help — SHIP counselors are free and can advocate on your behalf with your plan.

Costs during different stages of Medicare coverage

Your Part D costs for Zegerid change depending on where you are in the coverage year. In the deductible stage (early in the year), you pay the full price of the medication until you reach your plan's deductible amount. Once you meet the deductible, you move to the copay stage, where you pay a fixed copay amount. If your drug costs are very high, you may eventually reach the catastrophic coverage stage, where Medicare pays most of the cost and you pay a small copay.

Because Zegerid is a brand-name drug, it may count toward your deductible faster than a generic would. If cost is a concern, ask your doctor about starting with generic omeprazole early in the year, when deductible costs are highest. You can always switch to Zegerid later if the generic does not work well for you.

Frequently Asked Questions

Does Medicare Part A or Part B cover Zegerid?

Part A covers Zegerid only if you receive it as an inpatient in a hospital or skilled nursing facility — the medication is included in your daily facility charge, not billed separately. Part B does not cover Zegerid because it is an oral medication taken at home. Part D is the part that covers Zegerid for outpatient use.

Can I use a GoodRx coupon or discount card instead of my Medicare Part D plan?

You can use a discount card to pay cash for Zegerid, but if you do, that cost does not count toward your Part D deductible or out-of-pocket maximum. In most cases, using your Part D plan is cheaper because the plan's negotiated price is lower than the cash price, and the cost counts toward your coverage limits.

What if I switch Medicare plans — will my Zegerid coverage change?

Yes, coverage can change when you switch plans. Each plan has its own formulary, so a drug covered by one plan may not be covered by another. You can review formularies for plans you are considering during the annual enrollment period (October 15 to December 7) before you switch.

Is there a brand-name version of omeprazole that might be covered differently than Zegerid?

Prilosec is another brand-name version of omeprazole, but it is usually covered the same way as Zegerid by Part D plans — on a higher tier than generic omeprazole. Both brand-name versions cost more than the generic, and both may require prior authorization or step therapy.

Can my doctor request a formulary exception if my plan does not cover Zegerid?

Yes. Your doctor can request a formulary exception, which asks the plan to cover a drug that is not on the formulary or to waive step therapy requirements. The plan reviews the request and decides whether to grant it. Formulary exceptions are most likely to be approved when your doctor explains that you have tried alternatives and they did not work.