Potassium Exchangers
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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 53436001001 | VELTASSA | patiromer calcium sorbitex | POWD PACK | 1 gram | N | Y | PA Document |
| 53436001060 | VELTASSA | patiromer calcium sorbitex | POWD PACK | 1 gram | N | Y | PA Document |
| 53436016801 | VELTASSA | patiromer calcium sorbitex | POWD PACK | 16.8 gram | N | Y | PA Document |
| 53436016830 | VELTASSA | patiromer calcium sorbitex | POWD PACK | 16.8 gram | N | Y | PA Document |
| 53436025201 | VELTASSA | patiromer calcium sorbitex | POWD PACK | 25.2 gram | N | Y | PA Document |
| 53436025230 | VELTASSA | patiromer calcium sorbitex | POWD PACK | 25.2 gram | N | Y | PA Document |
| 53436008401 | VELTASSA | patiromer calcium sorbitex | POWD PACK | 8.4 gram | N | Y | PA Document |
| 53436008404 | VELTASSA | patiromer calcium sorbitex | POWD PACK | 8.4 gram | N | Y | PA Document |
| 53436008430 | VELTASSA | patiromer calcium sorbitex | POWD PACK | 8.4 gram | N | Y | PA Document |
| 46287000604 | SPS | sodium polystyrene sulfon/sorb | ENEMA | 30 gram-40 gram/120 mL | N | Y | |
| 62559035601 | KIONEX | sodium polystyrene sulfon/sorb | ORAL SUSP | 15 gram-20 gram/60 mL | N | Y | |
| 62559035660 | KIONEX | sodium polystyrene sulfon/sorb | ORAL SUSP | 15 gram-20 gram/60 mL | N | Y | |
| 46287000601 | SPS | sodium polystyrene sulfon/sorb | ORAL SUSP | 15 gram-20 gram/60 mL | N | Y | |
| 46287000660 | SPS | sodium polystyrene sulfon/sorb | ORAL SUSP | 15 gram-20 gram/60 mL | N | Y | |
| 00310111001 | LOKELMA | sodium zirconium cyclosilicate | POWD PACK | 10 gram | N | Y | PA Document |
| 00310111030 | LOKELMA | sodium zirconium cyclosilicate | POWD PACK | 10 gram | N | Y | PA Document |
| 00310111039 | LOKELMA | sodium zirconium cyclosilicate | POWD PACK | 10 gram | N | Y | PA Document |
| 00310110501 | LOKELMA | sodium zirconium cyclosilicate | POWD PACK | 5 gram | N | Y | PA Document |
| 00310110530 | LOKELMA | sodium zirconium cyclosilicate | POWD PACK | 5 gram | N | Y | PA Document |
| 00310110539 | LOKELMA | sodium zirconium cyclosilicate | POWD PACK | 5 gram | N | Y | PA Document |