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.
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 CALCIUM ACETATE TABLET Y    
calcium acetate CALPHRON TABLET Y    
calcium acetate ACETICAL 170 TABLET Y    
sevelamer carbonate SEVELAMER CARBONATE TABLET Y    
sevelamer carbonate RENVELA TABLET Y    
sevelamer HCl SEVELAMER HCL TABLET Y    
sevelamer HCl RENAGEL 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 FOSRENOL TAB CHEW N PA Document  
lanthanum carbonate LANTHANUM CARBONATE 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