Voquezna®
Drug - Voquezna® (vonoprazan) [Phatom Pharmaceuticals]
Voquezna DualPak® (vonoprazan, amoxicillin) [Phatom Pharmaceuticals]
Voquezna TriplePak® (vonoprazan, amoxicillin, clarithromycin) [Phatom Pharmaceuticals]
January 2025
Therapeutic area - H. Pylori treatment
Approval criteria:
Voquezna
- Patient is 18 years of age or older; AND
- Patient has a diagnosis of erosive esophagitis; AND
- Patient has a trial and failure, contraindication, or intolerance to the preferred proton pump inhibitors (PPIs) (e.g., omeprazole esomeprazole, pantoprazole, lansoprazole); AND
- Voquezna is prescribed by, or in consultation with, a gastrointestinal specialist
Voquezna DualPak or Voquezna TriplePak
- Patient is 18 years of age or older; AND
- Patient has a diagnosis of H. Pylori
- Patient has a trial and failure, contraindication, or intolerance to one of the following first line treatment regimens:
- Clarithromycin based therapy (e.g., clarithromycin based triple therapy, clarithromycin based concomitant therapy) OR
- Bismuth quadruple therapy (e.g., bismuth and metronidazole and tetracycline and proton pump inhibitor [PPI]) AND
- Voquezna DualPak or Voquezna TriplePak is prescribed by, or in consultation with, a gastrointestinal specialist
Quantity limits
Voquezna
- Healing of erosive esophagitis: 20 mg once daily for 8 weeks.
- Maintenance of healed erosive esophagitis: 10 mg once daily for up to 6 months.
- Requested tablet strength(s), quantity, refills, and the corresponding days supplied must be clearly stated on the prior authorization request form.
Voquezna DualPak or Voquezna TriplePak
- One carton of 14 daily administration packs
Questions?
Provider Call Center (844) 575-7887
