Xphozah — Medical Mutual

Initial criteria

• Patient is age ≥ 18 years; AND
• Patient has chronic kidney disease (CKD); AND
• Patient has been on maintenance dialysis for ≥ 3 months; AND
• Patient’s serum phosphate level is ≥ 5.5 mg/dL and < 10.0 mg/dL; AND
• Patient meets one of the following (i or ii):
• i. Patient meets both of the following (a and b):
• a) Patient has tried at least two phosphate binders; AND
• b) Patient had an inadequate response and/or intolerance to at least two phosphate binders; OR
• ii. Patient meets one of the following (a or b):
• a) Patient has a contraindication to at least two phosphate binders; OR
• b) Patient meets both of the following (1 and 2):
• (1) Patient has inadequate response and/or intolerance to at least one phosphate binder; AND
• (2) Patient has a contraindication to at least one phosphate binder;
• The medication is prescribed by or on consultation with a nephrologist.

Reauthorization criteria

• Response to therapy is required for continuation of therapy unless otherwise noted.

Approval duration

12 months initial, 12 months reauth