Pokonza (potassium chloride for oral solution) — Highmark
prophylaxis of hypokalemia
Preferred products
- potassium chloride oral tablets
- potassium chloride oral capsules
Initial criteria
- The member meets one (1) of the following criteria (1. or 2.):
- 1. The member is using Pokonza for treatment of hypokalemia. (ICD-10: E87.6, P74.32)
- OR
- 2. The member is using Pokonza for prophylaxis of hypokalemia. (ICD-10: E87.6, P74.32)
- AND The member meets one (1) of the following (1. or 2.):
- 1. The prescriber attests that dietary management with potassium-rich foods is insufficient.
- OR
- 2. If the member is receiving concomitant diuretics, the prescriber attests that diuretic dose reduction has been insufficient.
- AND If the member is 18 years of age or older, the member has experienced therapeutic failure or intolerance to all of the following plan-preferred products:
- 1. Potassium chloride oral tablets
- 2. Potassium chloride oral capsules
- AND The member has an inability to swallow solid oral dosage forms.
Reauthorization criteria
- The member requires continued therapy with Pokonza.
- The member continues to have an inability to swallow solid oral dosage forms.
Approval duration
12 months