KONVOMEP (omeprazole and sodium bicarbonate)

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.