Chelating / Binding Agents

deferasirox (Jadenu®, Jandenu® Sprinkle) and deferiprone (Ferriprox®) Approval Criteria:

• An FDA approved diagnosis; AND
• A patient-specific, clinically significant reason other than convenience why member cannot use Exjade® (deferasirox) must be provided; AND
• For Jadenu® Sprinkle (deferasirox oral granules), an age restriction of six years and younger will apply.  Members older than six years of age will require a patient-specific, clinically significant reason why Jadenu® oral tablets cannot be used even when the tablets are crushed; AND
• The member’s recent weight must be provided on the prior authorization request in order to authorize the appropriate amount of drug required according to package labeling.

lanthanum carbonate (Fosrenol®) Chewable Tablets, 750mg Oral Powder, and 1,000mg Oral Powder Approval Criteria:

• A diagnosis of hyperphosphatemia in patients with end stage renal disease (ESRD); AND
• Documented trials of inadequate response to at least two of the phosphate binders available without a prior authorization or a patient-specific, clinically significant reason why the member cannot use a phosphate binder available without a prior authorization; AND
• For the approval of Fosrenol® oral powder, a patient-specific, clinically significant reason why a special formulation is needed over a phosphate binder available without a prior authorization, such as brand Fosrenol® 500mg or 750mg chewable tablets which can be crushed, must be provided; AND
• For the approval of Fosrenol® 1,000mg chewable tablets, a patient-specific, clinically significant reason why the member cannot use a phosphate binder available without a prior authorization, such as Fosrenol® 500mg or 750mg chewable tablets, must be provided. 
• Fosrenol® 500mg or 750mg chewable tablets are brand preferred. Authorization of the generic formulation requires a patient-specific, clinically significant reason why the member cannot use the brand formulation.

patiromer (Veltassa®) Approval Criteria:

• An FDA approved diagnosis of hyperkalemia; AND
• Medications known to cause hyperkalemia [e.g., angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), aldosterone antagonists, nonsteroidal anti-inflammatory drugs (NSAIDs)] have been discontinued or reduced to the lowest effective dose where clinically appropriate; AND
• A trial of a potassium-eliminating diuretic or documentation why a diuretic is not appropriate for the member; AND
• Documentation of a low potassium diet; AND
• A quantity limit of 30 packets per month will apply.

sodium zirconium cyclosilicate (Lokelma™) Approval Criteria:  

• An FDA approved diagnosis of hyperkalemia; AND
• Medications known to cause hyperkalemia [e.g., angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), aldosterone antagonists, nonsteroidal anti-inflammatory drugs (NSAIDs)] have been discontinued or reduced to the lowest effective dose where clinically appropriate; AND
• A trial of a potassium-eliminating diuretic or documentation why a diuretic is not appropriate for the member; AND
• Documentation of a low potassium diet; AND
• A quantity limit of 30 packets per month will apply. Quantity limit overrides will be granted to allow for initial 3 times daily dosing. 

sucroferric oxyhydroxide (Velphoro®) Approval Criteria:

• A diagnosis of hyperphosphatemia in patients with chronic kidney disease (CKD) on dialysis; OR
• Documented trials of inadequate response to at least two of the phosphate binders available without a prior authorization or a patient-specific, clinically significant reason why the member cannot use a phosphate binder available without a prior authorization.  

ferric citrate (Auryxia™) Approval Criteria

• An FDA approved diagnosis of hyperphosphatemia in patients with chronic kidney disease (CKD) on dialysis; AND
• Documented trials of inadequate response to at least two of the phosphate binders available without a prior authorization or a patient-specific, clinically significant reason why the member cannot use a phosphate binder available without a prior authorization; OR  
• An FDA approved diagnosis of iron deficiency anemia (IDA) in patients with CKD not on dialysis; AND
• Documented lab results verifying IDA; AND
• A documented intolerance or inadequate response to prior treatment with oral iron.  
• A quantity limit of 12 tablets per day will apply based on maximum recommended dose.  

Prior Authorization form

If you have questions please call the Pharmacy Help Desk at (800) 522-0114 option 4 or (405) 522-6205 option 4.