Phosphate Binders & Absorption Inhibitors

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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.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
00054008813 CALCIUM ACETATE calcium acetate CAPSULE 667 mg Y Y N  
00054008826 CALCIUM ACETATE calcium acetate CAPSULE 667 mg Y Y N  
00781208102 CALCIUM ACETATE calcium acetate CAPSULE 667 mg Y Y N  
00904711906 CALCIUM ACETATE calcium acetate CAPSULE 667 mg Y Y N  
00904711961 CALCIUM ACETATE calcium acetate CAPSULE 667 mg Y Y N  
16571081320 CALCIUM ACETATE calcium acetate CAPSULE 667 mg Y Y N  
23155053102 CALCIUM ACETATE calcium acetate CAPSULE 667 mg Y Y N  
62135019122 CALCIUM ACETATE calcium acetate CAPSULE 667 mg Y Y N  
68084047901 CALCIUM ACETATE calcium acetate CAPSULE 667 mg Y Y N  
68084047911 CALCIUM ACETATE calcium acetate CAPSULE 667 mg Y Y N  
68094004459 CALCIUM ACETATE calcium acetate CAPSULE 667 mg Y Y N  
68094004461 CALCIUM ACETATE calcium acetate CAPSULE 667 mg Y Y N  
69097086283 CALCIUM ACETATE calcium acetate CAPSULE 667 mg Y Y N  
69367041102 CALCIUM ACETATE calcium acetate CAPSULE 667 mg Y Y N  
75834032302 CALCIUM ACETATE calcium acetate CAPSULE 667 mg Y Y N  
76282037702 CALCIUM ACETATE calcium acetate CAPSULE 667 mg Y Y N  
00536133632 CALCIUM ACETATE calcium acetate TABLET 667 mg Y Y N  
23155062102 CALCIUM ACETATE calcium acetate TABLET 667 mg Y Y N  
62135019222 CALCIUM ACETATE calcium acetate TABLET 667 mg Y Y N  
71321080320 CALCIUM ACETATE calcium acetate TABLET 667 mg Y Y N  
59528033102 CALPHRON calcium acetate TABLET 667 mg Y Y N  
10542004550 CALCIUM ACETATE calcium acetate TABLET 668 mg (169 mg calcium) N Y N Pharmacy PA
10542017020 ACETICAL 170 calcium acetate TABLET 670 mg Y Y N  
59528050805 MAGNEBIND 300 calcium carbonate/mag carb TABLET 250 mg-300 mg N Y N Pharmacy PA
59528041605 MAGNEBIND 400 calcium carbonate/mag carb TABLET 80 mg-115 mg N Y N Pharmacy PA
59922063101 AURYXIA ferric citrate TABLET 210 mg iron N Y N Pharmacy PA
00378289520 FERRIC CITRATE ferric citrate TABLET 210 mg iron N Y N Pharmacy PA
54092025701 FOSRENOL lanthanum carbonate POWD PACK 1,000 mg N Y N Pharmacy PA
54092025702 FOSRENOL lanthanum carbonate POWD PACK 1,000 mg N Y N Pharmacy PA
54092025601 FOSRENOL lanthanum carbonate POWD PACK 750 mg N Y N Pharmacy PA
54092025602 FOSRENOL lanthanum carbonate POWD PACK 750 mg N Y N Pharmacy PA
54092025410 FOSRENOL lanthanum carbonate TAB CHEW 1,000 mg N Y N Pharmacy PA
54092025490 FOSRENOL lanthanum carbonate TAB CHEW 1,000 mg N Y N Pharmacy PA
00093594040 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 1,000 mg N Y N Pharmacy PA
00093594098 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 1,000 mg N Y N Pharmacy PA
66993042475 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 1,000 mg N Y N Pharmacy PA
66993042485 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 1,000 mg N Y N Pharmacy PA
67877025890 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 1,000 mg N Y N Pharmacy PA
68180082110 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 1,000 mg N Y N Pharmacy PA
68180082147 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 1,000 mg N Y N Pharmacy PA
69097093665 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 1,000 mg N Y N Pharmacy PA
69097093698 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 1,000 mg N Y N Pharmacy PA
76282047813 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 1,000 mg N Y N Pharmacy PA
76282047890 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 1,000 mg N Y N Pharmacy PA
54092025245 FOSRENOL lanthanum carbonate TAB CHEW 500 mg N Y N Pharmacy PA
54092025290 FOSRENOL lanthanum carbonate TAB CHEW 500 mg N Y N Pharmacy PA
00093593854 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 500 mg N Y N Pharmacy PA
00093593898 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 500 mg N Y N Pharmacy PA
66993042247 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 500 mg N Y N Pharmacy PA
66993042285 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 500 mg N Y N Pharmacy PA
67877025690 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 500 mg N Y N Pharmacy PA
68180081942 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 500 mg N Y N Pharmacy PA
68180081952 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 500 mg N Y N Pharmacy PA
69097093457 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 500 mg N Y N Pharmacy PA
69097093498 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 500 mg N Y N Pharmacy PA
76282047645 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 500 mg N Y N Pharmacy PA
76282047690 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 500 mg N Y N Pharmacy PA
54092025315 FOSRENOL lanthanum carbonate TAB CHEW 750 mg N Y N Pharmacy PA
54092025390 FOSRENOL lanthanum carbonate TAB CHEW 750 mg N Y N Pharmacy PA
00093593985 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 750 mg N Y N Pharmacy PA
00093593998 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 750 mg N Y N Pharmacy PA
66993042353 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 750 mg N Y N Pharmacy PA
66993042385 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 750 mg N Y N Pharmacy PA
67877025790 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 750 mg N Y N Pharmacy PA
68180082046 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 750 mg N Y N Pharmacy PA
68180082053 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 750 mg N Y N Pharmacy PA
69097093589 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 750 mg N Y N Pharmacy PA
69097093598 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 750 mg N Y N Pharmacy PA
76282047715 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 750 mg N Y N Pharmacy PA
76282047790 LANTHANUM CARBONATE lanthanum carbonate TAB CHEW 750 mg N Y N Pharmacy PA
58468013201 RENVELA sevelamer carbonate POWD PACK 0.8 gram N Y N Pharmacy PA
58468013202 RENVELA sevelamer carbonate POWD PACK 0.8 gram N Y N Pharmacy PA
00115136529 SEVELAMER CARBONATE sevelamer carbonate POWD PACK 0.8 gram N Y N Pharmacy PA
00115136530 SEVELAMER CARBONATE sevelamer carbonate POWD PACK 0.8 gram N Y N Pharmacy PA
33342028868 SEVELAMER CARBONATE sevelamer carbonate POWD PACK 0.8 gram N Y N Pharmacy PA
43598047801 SEVELAMER CARBONATE sevelamer carbonate POWD PACK 0.8 gram N Y N Pharmacy PA
43598047890 SEVELAMER CARBONATE sevelamer carbonate POWD PACK 0.8 gram N Y N Pharmacy PA
64380088000 SEVELAMER CARBONATE sevelamer carbonate POWD PACK 0.8 gram N Y N Pharmacy PA
64380088080 SEVELAMER CARBONATE sevelamer carbonate POWD PACK 0.8 gram N Y N Pharmacy PA
65862093008 SEVELAMER CARBONATE sevelamer carbonate POWD PACK 0.8 gram N Y N Pharmacy PA
65862093090 SEVELAMER CARBONATE sevelamer carbonate POWD PACK 0.8 gram N Y N Pharmacy PA
69452012619 SEVELAMER CARBONATE sevelamer carbonate POWD PACK 0.8 gram N Y N Pharmacy PA
69452012660 SEVELAMER CARBONATE sevelamer carbonate POWD PACK 0.8 gram N Y N Pharmacy PA
72603039801 SEVELAMER CARBONATE sevelamer carbonate POWD PACK 0.8 gram N Y N Pharmacy PA
72603039802 SEVELAMER CARBONATE sevelamer carbonate POWD PACK 0.8 gram N Y N Pharmacy PA
58468013101 RENVELA sevelamer carbonate POWD PACK 2.4 gram N Y N Pharmacy PA
58468013102 RENVELA sevelamer carbonate POWD PACK 2.4 gram N Y N Pharmacy PA
00115136629 SEVELAMER CARBONATE sevelamer carbonate POWD PACK 2.4 gram N Y N Pharmacy PA
00115136630 SEVELAMER CARBONATE sevelamer carbonate POWD PACK 2.4 gram N Y N Pharmacy PA
33342028968 SEVELAMER CARBONATE sevelamer carbonate POWD PACK 2.4 gram N Y N Pharmacy PA
43598047901 SEVELAMER CARBONATE sevelamer carbonate POWD PACK 2.4 gram N Y N Pharmacy PA
43598047990 SEVELAMER CARBONATE sevelamer carbonate POWD PACK 2.4 gram N Y N Pharmacy PA
64380088100 SEVELAMER CARBONATE sevelamer carbonate POWD PACK 2.4 gram N Y N Pharmacy PA
64380088180 SEVELAMER CARBONATE sevelamer carbonate POWD PACK 2.4 gram N Y N Pharmacy PA
65862093108 SEVELAMER CARBONATE sevelamer carbonate POWD PACK 2.4 gram N Y N Pharmacy PA
65862093190 SEVELAMER CARBONATE sevelamer carbonate POWD PACK 2.4 gram N Y N Pharmacy PA
69452012719 SEVELAMER CARBONATE sevelamer carbonate POWD PACK 2.4 gram N Y N Pharmacy PA
69452012760 SEVELAMER CARBONATE sevelamer carbonate POWD PACK 2.4 gram N Y N Pharmacy PA
58468013301 RENVELA sevelamer carbonate TABLET 800 mg Y Y N  
00781521932 SEVELAMER CARBONATE sevelamer carbonate TABLET 800 mg Y Y N  
00904670706 SEVELAMER CARBONATE sevelamer carbonate TABLET 800 mg Y Y N  
00904670782 SEVELAMER CARBONATE sevelamer carbonate TABLET 800 mg Y Y N  
00955105027 SEVELAMER CARBONATE sevelamer carbonate TABLET 800 mg Y Y N  
16571073927 SEVELAMER CARBONATE sevelamer carbonate TABLET 800 mg Y Y N  
16714081401 SEVELAMER CARBONATE sevelamer carbonate TABLET 800 mg Y Y N  
24979018646 SEVELAMER CARBONATE sevelamer carbonate TABLET 800 mg Y Y N  
33342021558 SEVELAMER CARBONATE sevelamer carbonate TABLET 800 mg Y Y N  
50268072011 SEVELAMER CARBONATE sevelamer carbonate TABLET 800 mg Y Y N  
50268072015 SEVELAMER CARBONATE sevelamer carbonate TABLET 800 mg Y Y N  
55111078911 SEVELAMER CARBONATE sevelamer carbonate TABLET 800 mg Y Y N  
55111078927 SEVELAMER CARBONATE sevelamer carbonate TABLET 800 mg Y Y N  
55111078948 SEVELAMER CARBONATE sevelamer carbonate TABLET 800 mg Y Y N  
60687032811 SEVELAMER CARBONATE sevelamer carbonate TABLET 800 mg Y Y N  
60687032831 SEVELAMER CARBONATE sevelamer carbonate TABLET 800 mg Y Y N  
60687032833 SEVELAMER CARBONATE sevelamer carbonate TABLET 800 mg Y Y N  
60687032865 SEVELAMER CARBONATE sevelamer carbonate TABLET 800 mg Y Y N  
64380087267 SEVELAMER CARBONATE sevelamer carbonate TABLET 800 mg Y Y N  
65162005827 SEVELAMER CARBONATE sevelamer carbonate TABLET 800 mg Y Y N  
65862092127 SEVELAMER CARBONATE sevelamer carbonate TABLET 800 mg Y Y N  
68094003459 SEVELAMER CARBONATE sevelamer carbonate TABLET 800 mg Y Y N  
68094003464 SEVELAMER CARBONATE sevelamer carbonate TABLET 800 mg Y Y N  
69097096793 SEVELAMER CARBONATE sevelamer carbonate TABLET 800 mg Y Y N  
76282040727 SEVELAMER CARBONATE sevelamer carbonate TABLET 800 mg Y Y N  
33342024165 SEVELAMER HCL sevelamer HCl TABLET 400 mg N Y N Pharmacy PA
59651008736 SEVELAMER HCL sevelamer HCl TABLET 400 mg N Y N Pharmacy PA
68462044626 SEVELAMER HCL sevelamer HCl TABLET 400 mg N Y N Pharmacy PA
00904720906 SEVELAMER HCL sevelamer HCl TABLET 800 mg N Y N Pharmacy PA
00955104818 SEVELAMER HCL sevelamer HCl TABLET 800 mg N Y N Pharmacy PA
33342024257 SEVELAMER HCL sevelamer HCl TABLET 800 mg N Y N Pharmacy PA
59651008818 SEVELAMER HCL sevelamer HCl TABLET 800 mg N Y N Pharmacy PA
60687044901 SEVELAMER HCL sevelamer HCl TABLET 800 mg N Y N Pharmacy PA
60687044911 SEVELAMER HCL sevelamer HCl TABLET 800 mg N Y N Pharmacy PA
68462044718 SEVELAMER HCL sevelamer HCl TABLET 800 mg N Y N Pharmacy PA
70710205808 SEVELAMER HCL sevelamer HCl TABLET 800 mg N Y N Pharmacy PA
70748017326 SEVELAMER HCL sevelamer HCl TABLET 800 mg N Y N Pharmacy PA
72603014801 SEVELAMER HCL sevelamer HCl TABLET 800 mg N Y N Pharmacy PA
72603036101 SEVELAMER HCL sevelamer HCl TABLET 800 mg N Y N Pharmacy PA
49230064551 VELPHORO sucroferric oxyhydroxide TAB CHEW 500 mg iron N Y N Pharmacy PA
73154012060 XPHOZAH tenapanor HCl TABLET 20 mg N Y N Pharmacy PA
73154013060 XPHOZAH tenapanor HCl TABLET 30 mg N Y N Pharmacy PA
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