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