tenapanor — Blue Cross Blue Shield of Kansas

Preferred products

• ferric citrate 1 gm (210 mg ferric iron)

Initial criteria

• The patient has a diagnosis of chronic kidney disease (CKD)
• The patient is on dialysis
• The patient has a phosphorus level of at least 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 an intolerance or hypersensitivity to ONE prerequisite agent OR has an FDA labeled contraindication to ALL prerequisite agents
• The patient has tried and had an inadequate response to ONE preferred agent (ferric citrate 1 gm [210 mg ferric iron]) OR has an intolerance or hypersensitivity to ONE preferred agent OR has an FDA labeled contraindication to ALL preferred 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’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 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