Xphozah — Blue Cross Blue Shield of Alabama

Preferred products

• calcium carbonate
• calcium acetate
• calcium with magnesium
• lanthanum carbonate
• sevelamer carbonate
• sevelamer HCl

Initial criteria

• The patient has a diagnosis of chronic kidney disease (CKD) AND is on dialysis AND has a phosphorus level ≥ 5.5 mg/dL
• The patient has tried and had an inadequate response to at least ONE prerequisite agent (calcium carbonate, calcium acetate, calcium with magnesium, lanthanum carbonate, sevelamer carbonate, sevelamer HCl) OR has intolerance or hypersensitivity to ONE prerequisite agent OR has an FDA labeled contraindication to ALL prerequisite agents
• The patient will be using phosphate binder therapy in combination with the requested agent OR the patient has an intolerance, hypersensitivity, or FDA labeled contraindication to phosphate binder therapy
• The patient has another FDA labeled indication for the requested agent and route of administration
• If the patient has an FDA labeled indication, then ONE of the following: the patient’s age is within FDA labeling for the requested indication OR there is support for using the requested agent for the patient’s age for the requested indication
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., nephrologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

3 months