Xphozah — Blue Cross Blue Shield of Oklahoma

Preferred products

• ferric citrate 1 gm (210 mg ferric iron)
• calcium carbonate
• calcium acetate
• calcium with magnesium
• lanthanum carbonate
• sevelamer carbonate
• sevelamer HCl

Initial criteria

• ONE of the following: (A) Prescriber states patient has been treated with the requested agent within the past 90 days and is at risk if therapy is changed OR (B) Patient has stage four advanced, metastatic cancer being treated with or with associated condition treated by the agent and use is consistent with best practices OR (C) Patient meets the following CKD criteria AND all subrequirements:
• For CKD indication: (1) Diagnosis of chronic kidney disease (CKD) AND patient is on dialysis AND phosphorus level ≥ 5.5 mg/dL
• AND ONE of the following group A conditions: (1) Request is for BCBS IL Fully Insured, HIM, or Non‑ERISA ASO/Self‑insured Municipalities/Counties member OR (2) Patient is currently on and stable with requested agent [chart notes required] OR (3) Patient tried and had inadequate response to ≥1 prerequisite agent [chart notes required] OR (4) A prerequisite agent discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required] OR (5) A prerequisite agent expected to be ineffective or cause barrier/adverse reaction [chart notes required] OR (6) A prerequisite agent not in the best interest medically [chart notes required] OR (7) Tried another drug in same pharmacologic class resulting in discontinuation due to lack of efficacy/effectiveness/adverse event [chart notes required]
• AND ONE of the following group B conditions referencing preferred agent(s): (1) Request is for BCBS IL Fully Insured, HIM or Non‑ERISA member OR (2) Patient currently treated and stable on requested agent [chart notes required] OR (3) Inadequate response to ≥1 preferred agent [chart notes required] OR (4) Preferred discontinued for lack of efficacy/effectiveness/adverse event [chart notes required] OR (5) Preferred expected ineffective/adverse/barrier [chart notes required] OR (6) Preferred not in best interest [chart notes required] OR (7) Tried another same‑class agent and discontinued for ineffectiveness/adverse event [chart notes required] AND (8) Will use in combination with preferred agent [chart notes required] OR (9) Intolerance/hypersensitivity to ≥1 preferred agent [chart notes required] OR (10) FDA labeled contraindication to all preferred agent(s) [chart notes required]
• AND ONE of the following: (A) Using phosphate binder therapy in combination with requested agent OR (B) Has intolerance/hypersensitivity/FDA contraindication to phosphate binder therapy
• AND Patient has FDA labeled indication for requested agent
• AND Age within FDA labeling or supported for indication
• AND Prescriber is a specialist or has consulted a relevant specialist
• AND No FDA labeled contraindications to requested agent

Approval duration

BCBSIL/BCBSMT: 12 months; others: 3 months; certain rare disease or Ohio exceptions: 12 months