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:
- 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:
- Konvomep Prescribing Information. Azurity Pharmaceuticals, Inc. Woburn, MA. December 2022.
Last review date: March 1, 2024