tenapanor hcl — Blue Cross Blue Shield of Montana

Preferred products

• Ferric citrate 1 gm (210 mg ferric iron)

Initial criteria

• Patient must meet ONE of the following: A. Has been treated with the requested agent within the past 90 days and is at risk if therapy is changed; OR B. Has stage four advanced, metastatic cancer and agent used for cancer or associated condition consistent with best practices and FDA approval; OR C. Has diagnosis of chronic kidney disease (CKD) AND patient is on dialysis AND phosphorus level ≥5.5 mg/dL AND ALL of the following:
• — ONE of the following: (1) Request is for BCBS IL Fully Insured, HIM, or Non‑ERISA ASO/Self‑insured Municipalities/Counties member; OR (2) Patient currently treated and stable on requested agent [chart notes required]; OR (3) Patient tried and had inadequate response to ≥1 prerequisite agent (calcium carbonate, calcium acetate, calcium with magnesium, lanthanum carbonate, sevelamer carbonate, sevelamer HCl) [chart notes required]; OR (4) One prerequisite agent discontinued due to lack of efficacy/effectiveness, diminished effect, or adverse event [chart notes required]; OR (5) One prerequisite agent expected to be ineffective or unsafe or not in best interest [chart notes required]; OR (7) Tried another drug in same class discontinued due to lack of efficacy/effectiveness or adverse event [chart notes required];
• — AND ONE of the following relative to preferred agent(s) Ferric citrate 1 gm (210 mg ferric iron): (1) Request for BCBS IL Fully Insured, HIM, or Non‑ERISA ASO/Self‑insured Municipalities/Counties member; OR (2) Patient currently stable on requested agent; OR (3) Tried and had inadequate response to ≥1 preferred agent; OR (4) Preferred agent discontinued due to lack of efficacy/effectiveness or adverse event; OR (5) Preferred agent expected to be ineffective or unsafe or not in best interest; OR (7) Tried another drug in same class with same mechanism discontinued due to lack of efficacy/effectiveness or adverse event; OR (8) Requested agent will be used in combination with preferred agent; OR (9) Patient intolerant or hypersensitive to one preferred agent; OR (10) Patient has FDA‑labeled contraindication to all preferred agent(s);
• — AND ONE of the following: (A) Patient will use phosphate binder therapy in combination with requested agent; OR (B) Patient has intolerance, hypersensitivity, or FDA contraindication to phosphate binder therapy;
• — Patient has another FDA labeled indication for requested agent and route of administration;
• — If FDA labeled indication present, patient’s age is within or supported for labeled indication;
• — Prescriber is a specialist (e.g., nephrologist) or has consulted a specialist;
• — Patient has no FDA labeled contraindication to requested agent.
• For select NM or OH members: rare disease or compendia or journal evidence criteria as specified may also allow approval.

Approval duration

12 months (BCBSIL and BCBSMT); 3 months (others)