Rayaldee (calcifediol) — Highmark
secondary hyperparathyroidism in adults with stage 3 or 4 chronic kidney disease (CKD) and serum total 25-hydroxyvitamin D levels < 30 ng/mL
Preferred products
- calcitriol
- paricalcitol
Initial criteria
- age ≥ 18 years
- diagnosis of secondary hyperparathyroidism (ICD-10: E21.1, N25.81)
- diagnosis of stage 3 or 4 chronic kidney disease (ICD-10: N18.3, N18.31, N18.32, N18.4)
- prescriber provides documentation of serum total 25-hydroxyvitamin D level < 30 ng/mL AND serum calcium < 9.8 mg/dL
- member has experienced therapeutic failure, contraindication, or intolerance to one of the following plan-preferred products: calcitriol OR paricalcitol
Reauthorization criteria
- prescriber attests that the member has experienced positive clinical response to therapy
- prescriber provides documentation of serum total 25-hydroxyvitamin D level < 100 ng/mL AND serum calcium < 9.8 mg/dL
Approval duration
12 months