Phosphate Binders

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
calcium acetate CALCIUM ACETATE CAPSULE Y    
calcium acetate ELIPHOS TABLET Y    
calcium acetate CALPHRON TABLET Y    
calcium acetate ACETICAL 170 TABLET Y    
calcium acetate CALCIUM ACETATE TABLET Y 668 mg (169 mg calcium) Require PA  
sevelamer HCl RENAGEL TABLET Y PA Document  
calcium acetate PHOSLYRA SOLUTION N    
calcium carb/mag carb/folic ac MAGNEBIND 400 RX TABLET N PA Document  
calcium carbonate/mag carb MAGNEBIND 300 TABLET N PA Document  
ferric citrate AURYXIA TABLET N PA Document Mar 31, 2016
lanthanum carbonate FOSRENOL POWD PACK N PA Document  
lanthanum carbonate LANTHANUM CARBONATE TAB CHEW N PA Document  
lanthanum carbonate FOSRENOL TAB CHEW N PA Document  
sevelamer carbonate SEVELAMER CARBONATE POWD PACK N PA Document  
sevelamer carbonate RENVELA POWD PACK N PA Document  
sevelamer carbonate SEVELAMER CARBONATE TABLET N PA Document  
sevelamer carbonate RENVELA TABLET N PA Document  
sodium polystyrene sulfon/sorb SPS ENEMA N PA Document  
sodium polystyrene sulfon/sorb SPS ORAL SUSP N PA Document  
sodium polystyrene sulfon/sorb KIONEX ORAL SUSP N PA Document  
sodium zirconium cyclosilicate LOKELMA POWD PACK N PA Document  
sucroferric oxyhydroxide VELPHORO TAB CHEW N PA Document