tenapanor hcl — Blue Cross Blue Shield of Texas

Preferred products

• Ferric citrate 1 gm (210 mg ferric iron)

Initial criteria

• ONE of the following: (A) Patient has been treated with the requested agent within past 90 days and is at risk if therapy is changed OR (B) Patient has stage IV metastatic cancer diagnosis and use per best practices OR (C) Patient meets ALL of the following:
• • Diagnosis of chronic kidney disease (CKD)
• • Patient is on dialysis
• • Patient has phosphorus level ≥ 5.5 mg/dL
• • ONE of the following regarding prerequisite agents (calcium carbonate, calcium acetate, calcium with magnesium, lanthanum carbonate, sevelamer carbonate, sevelamer HCl): member type criteria met, currently stable on agent, tried and failed at least one prerequisite, discontinued due to inefficacy/adverse event, expected ineffective or against best interest based on clinical characteristics, comorbidity, adherence barrier, or harm, OR tried similar drug in same class discontinued for inefficacy/adverse event
• • ONE of the following regarding preferred agent Ferric citrate 1 gm (210 mg ferric iron): applicable member plan type, currently stable, tried and failed at least one preferred agent, discontinued due to inefficacy/adverse event, expected ineffective or harmful based on patient characteristics, not in best interest medically necessary, tried drug in same class discontinued for adverse event, will use in combination with preferred agent, intolerant/hypersensitive, or has contraindication to all preferred agents
• • ONE of the following: patient will use phosphate binder therapy in combination OR has intolerance/hypersensitivity/contraindication to phosphate binder therapy
• • Patient has another FDA labeled indication for requested agent and route of administration
• • Patient age is within FDA labeling or supported for the indication
• • Prescriber is a specialist in the diagnosis area (e.g., nephrologist) or has consulted with one
• • Patient has no FDA labeled contraindications to requested agent
• Alternate criteria sections for BCBS NM/IL/MT/OH members allow approval for rare diseases or compendia-supported/peer-reviewed indications meeting plan conditions

Approval duration

12 months (BCBSIL and BCBSMT); 3 months (all other plans)