KONVOMEP (omeprazole and sodium bicarbonate)

Self-Administration – oral

Diagnosis considered for coverage:
  • Gastric Ulcer: Indicated for the short-term treatment (4 to 8 weeks) of active benign gastric ulcer in adults.
  • Reduction of Risk of Upper Gastrointestinal Bleeding in Critically Ill Patients: Indicated for the reduction of risk of upper gastrointestinal (GI) bleeding in critically ill adult patients.
Coverage Criteria:
  1. For all diagnoses:
  • Requested drug is being used for a Food and Drug Administration (FDA)-approved indication, AND
  • Trial and failure or intolerance to at least two of the following:
    • esomeprazole
    • lansoprazole (capsule)
    • omeprazole
    • pantoprazole
    • rabeprazole (tablets)
    • dexlansoprazole
Coverage Duration:
  • Initial: 8 weeks
Authorization is not covered for the following:

The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

Dosing:

Policy Updates:
  • 02/20/2024 – New policy approved by P&T.
References:
  1. Konvomep Prescribing Information. Azurity Pharmaceuticals, Inc. Woburn, MA. December 2022.

Last review date: March 1, 2024

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