Pharmacy Prior Authorization Criteria

Phosphate Binders

Indications for Prior Authorization

Fosrenol (lanthanum carbonate)

• For diagnosis of Hyperphosphatemia
  Indicated to reduce serum phosphate in patients with end-stage renal disease (ESRD).

Velphoro (sucroferric oxyhydroxide)

• For diagnosis of Hyperphosphatemia
  Indicated for the control of serum phosphorus levels in adult and pediatric patients 9 years of age and older with chronic kidney disease on dialysis.

Criteria

Velphoro

Step Therapy

Length of Approval: 12 Month(s)

• Both of the following:
• Diagnosis of hyperphosphatemia in chronic kidney disease on dialysis
AND
• One of the following:
• Trial and failure of a minimum 30-day supply, contraindication, or intolerance to two of the following:
• calcium carbonate
• calcium acetate
• sevelamer carbonate
• sevelamer HCl
• Auryxia
OR
• Patient is younger than or equal to 12 years of age

Brand Fosrenol

Step Therapy

Length of Approval: 12 Month(s)

• Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
AND
• Trial and failure of a minimum 30-day supply, contraindication, or intolerance to two of the following:
• calcium carbonate
• calcium acetate
• sevelamer carbonate
• sevelamer HCl

P & T Revisions

2025-12-02, 2024-08-26, 2024-05-18, 2023-05-24, 2022-05-31

References

1. Velphoro Prescribing Information. Fresenius Medical Care North America. Waltham, MA. July 2024.
2. Fosrenol Prescribing Information. Takeda Pharmaceutical Company Limited. Lexington, MA. May 2020.

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Revision History

• 2025-12-02: Removed Phoslyra as a target drug
• 2024-08-26: update guideline
• 2024-05-18: 2024 Annual Review
• 2023-05-24: 2023 Annual Review.
• 2022-05-31: New Program

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