CurrentUnitedHealthcarePolicy 2025 P 2328-3

Voquezna (vonoprazan) prior authorization

Defines UnitedHealthcare prior authorization and medical necessity criteria for Voquezna (vonoprazan) for adults, including use for erosive esophagitis, non-erosive GERD, and H. pylori treatment in combination therapy. Applies to providers submitting requests for coverage under UnitedHealthcare plans (state mandates may apply).

Policy Summary

PayerUnitedHealthcare

PolicyVoquezna (vonoprazan) prior authorization

Policy CodePolicy 2025 P 2328-3

Change TypeAdded coverage for GERDupdated step therapy agents

Effective DateApr 1, 2025

Next Review Date

Key ActionObtain prior authorization and document prior trial and failure, contraindication, or intolerance to one of: omeprazole, pantoprazole, or rabeprazole.

SourceLink

POLICY UPDATE CHANGES

Added coverage for GERD based on updated labeling.

Updated step one options to include omeprazole and pantoprazole.

New prior authorization program established for Voquezna.

9 monthsauth duration (EE/GERD)

1 monthauth duration (H. pylori)

3required trialed agents

2025-04-01effective

Policy Summary

PayerUnitedHealthcare

PolicyVoquezna (vonoprazan) prior authorization

Policy CodePolicy 2025 P 2328-3

Change TypeAdded coverage for GERDupdated step therapy agents

Effective DateApr 1, 2025

Next Review Date

Key ActionObtain prior authorization and document prior trial and failure, contraindication, or intolerance to one of: omeprazole, pantoprazole, or rabeprazole.

SourceLink

On This Page

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Initial therapy for erosive esophagitis or non-erosive GERD

Covered when ALL of the following are met:

Indication

Indication options: erosive esophagitis OR non-erosive GERD
See policy indications

Step therapy requirement: History of failure, contraindication, or intolerance to one of: omeprazole, pantoprazole, or rabeprazole

Required prior to approval

H. pylori combination therapy

Covered when ALL of the following are met:

Indication: Patient is receiving vonoprazan in combination with amoxicillin or amoxicillin and clarithromycin for treatment of Helicobacter pylori infection

Combination therapy required per labeling

Step therapy requirement: History of failure, contraindication, or intolerance to one of: omeprazole, pantoprazole, or rabeprazole

Required prior to approval

Supply limits may be in place. In addition, state mandates and the member-specific benefit plan may limit coverage for Voquezna (vonoprazan). Providers should verify applicable state requirements and the patient’s benefit plan prior to submitting an authorization request.

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required. Approvals are for 9 months when Voquezna is prescribed for erosive esophagitis or non-erosive GERD, and for 1 month when prescribed as part of H. pylori combination therapy with amoxicillin or amoxicillin plus clarithromycin.

Approvals: 9 months — erosive esophagitis or non‑erosive GERD
Approvals: 1 month — H. pylori combination therapy

Step Therapy

Step Therapy (PPI Trial)

Step therapy is required. Requests must document a history of failure, contraindication, or intolerance to one of the specified proton pump inhibitors (omeprazole, pantoprazole, or rabeprazole) before Voquezna will be approved.

Required trial and failure/contraindication/intolerance to one of: omeprazole, pantoprazole, rabeprazole

Documentation Required

Clinical documentation must clearly state the treated indication (erosive esophagitis, non‑erosive GERD, or H. pylori in combination therapy) and provide supporting details such as prior PPI use and reason for failure, contraindication, or intolerance.

Specify treated condition (erosive esophagitis, non‑erosive GERD, or H. pylori combination therapy)
Document prior PPI trial and reason for failure/contraindication/intolerance

Denial Risk

Missing Information May Result in Denial

Requests missing the treated indication or lacking documentation of required step therapy (PPI trial failure/contraindication/intolerance) are at risk for denial.

No approval without documented indication and PPI step therapy exception/failure details

Definitions

Voquezna (vonoprazan) — definition and indications

Drug classPotassium-competitive acid blocker (Voquezna, generic: vonoprazan)

FDA‑labeled indications (adults)Healing and maintenance of erosive esophagitis; relief of heartburn associated with erosive esophagitis and non‑erosive GERD; in combination with amoxicillin (with or without clarithromycin) for H. pylori eradication.

Coverage scope in this policyPrior authorization required for vonoprazan for adults when used for erosive esophagitis, non‑erosive GERD, or H. pylori combination therapy.

Step therapy requirementApproval requires history of failure, contraindication, or intolerance to one of: omeprazole, pantoprazole, or rabeprazole.

Authorization durationsApprovals issued for 9 months for erosive esophagitis/GERD indications and 1 month for H. pylori combination therapy.

Background

Vonoprazan (Voquezna) is a potassium-competitive acid blocker indicated for healing and maintenance of healing of erosive esophagitis and for relief of heartburn associated with erosive and non-erosive gastroesophageal reflux disease (GERD) in adults. It is also indicated, when used in combination with amoxicillin with or without clarithromycin, for eradication of Helicobacter pylori infection. Coverage in this policy is tied to these labeled indications and requires documentation consistent with the FDA-approved uses.

OpenPayer

Voquezna (vonoprazan) prior authorization

Coverage Criteria for Voquezna (vonoprazan)

Provider Requirements and Prior Authorization

Definitions

Background