Phosphate Binders & Absorption Inhibitors
PDL Reference Documents
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.
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 | ACETICAL 170 | TABLET | Y | ||
| calcium acetate | CALCIUM ACETATE | TABLET | Y | ||
| calcium acetate | CALPHRON | TABLET | Y | ||
| sevelamer carbonate | SEVELAMER CARBONATE | TABLET | Y | ||
| sevelamer carbonate | RENVELA | TABLET | Y | ||
| sevelamer HCl | SEVELAMER HCL | TABLET | Y | ||
| calcium acetate | PHOSLYRA | SOLUTION | N | PA Document | |
| calcium acetate | CALCIUM ACETATE | TABLET | N | PA Document | |
| calcium carbonate/mag carb | MAGNEBIND 300 | TABLET | N | PA Document | |
| calcium carbonate/mag carb | MAGNEBIND 400 | 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 | |
| sucroferric oxyhydroxide | VELPHORO | TAB CHEW | N | PA Document | |
| tenapanor HCl | XPHOZAH | TABLET | N | PA Document |