Pharmacy Prior Authorization Criteria

Xphozah (tenapanor) - ST, NF

Indications for Prior Authorization

Xphozah (tenapanor)

• For diagnosis of Hyperphosphatemia in Chronic Kidney Disease on Dialysis
  Indicated to reduce serum phosphorus in adults with chronic kidney disease (CKD) on dialysis as add-on therapy in patients who have an inadequate response to phosphate binders or who are intolerant of any dose of phosphate binder therapy.

Criteria

Xphozah

Step Therapy

Length of Approval: 12 Month(s)

• Diagnosis of hyperphosphatemia in chronic kidney disease
AND
• Patient is on dialysis
AND
• Trial (minimum 30-day supply) and inadequate response, contraindication or intolerance to two of the following: [A-B, 2-3]
• calcium carbonate
• calcium acetate
• lanthanum carbonate
• sevelamer carbonate
• sevelamer HCl
• Auryxia

Xphozah

Non Formulary

Length of Approval: 12 Month(s)

• Submission of medical records (e.g., chart notes) confirming diagnosis of hyperphosphatemia in chronic kidney disease
AND
• Patient is on dialysis
AND
• Submission of medical records (e.g., chart notes) or paid claims confirming trial (minimum 30-day supply) and inadequate response, contraindication or intolerance to two of the following: [A-B, 2-3]
• calcium carbonate
• calcium acetate
• lanthanum carbonate
• sevelamer carbonate
• sevelamer HCl
• Auryxia

P & T Revisions

2024-08-26, 2024-04-08, 2024-01-17, 2023-12-19

References

1. Xphozah [prescribing information]. Waltham, MA. Ardelyx Inc. October 2023.
2. UptoDate. Management of hyperphosphatemia in adults with chronic kidney disease. Available at: https://www.uptodate.com/contents/management-of-hyperphosphatemia-in-adults-with-chronic-kidney-disease?search=dialysis%20in%20chronic%20kidney%20disease&source=search_result&selectedTitle=4~150&usage_type=default&display_rank=4#H169682201. Accessed December 11, 2023.
3. KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder (CKD-MBD). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6340919/. Accessed December 11, 2023.

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Revision History

• 2024-08-26: update guideline
• 2024-04-08: update guideline
• 2024-01-17: update guideline
• 2023-12-19: New UM PA Criteria

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