Phosphate Binders

← Back to Class List

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 CALCIUM ACETATE TABLET Y    
CALCIUM ACETATE ACETICAL 170 TABLET Y    
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 FOSRENOL TAB CHEW N PA Document  
SEVELAMER CARBONATE RENVELA POWD PACK N PA Document  
SEVELAMER CARBONATE SEVELAMER CARBONATE POWD PACK 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  
SUCROFERRIC OXYHYDROXIDE VELPHORO TAB CHEW N PA Document