CurrentAvMedPolicy N/A

Potassium binders prior authorization (Lokelma, Veltassa)

This form governs prior authorization and step-edit requests for the potassium binders Lokelma (sodium zirconium cyclosilicate) and Veltassa (patiromer) for AvMed members; it describes required documentation and clinical criteria prescribers must meet to obtain or renew coverage.

Policy Summary

PayerAvMed

PolicyPotassium binders prior authorization (Lokelma, Veltassa)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit laboratory documentation showing baseline serum potassium >5.0 mEq/L and attest to prior diuretic trial if clinically appropriate.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 moInitial authorization duration

12 moReauthorization duration

>5.0Baseline K threshold

18Minimum age

Coverage criteria for potassium binders

Initial and Reauthorization Criteria

Covered when ALL of the following are met

Initial Authorization Criteria: Member is 18 years of age or older

Initial Authorization Criteria: Member has a diagnosis of chronic non-life threatening hyperkalemia

Initial Authorization Criteria: Provider has submitted laboratory documentation of serum potassium levels supporting hyperkalemia (baseline serum potassium >5.0 mEq/L)>5.0 mEq/L

Initial Authorization Criteria:

Policy Summary

PayerAvMed

PolicyPotassium binders prior authorization (Lokelma, Veltassa)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit laboratory documentation showing baseline serum potassium >5.0 mEq/L and attest to prior diuretic trial if clinically appropriate.

SourceLink

On This Page

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Prescriber attests, if clinically appropriate, member has tried and failed loop or thiazide diuretic therapy for potassium removal

Step therapy requirement; provider attestation required when appropriate

Initial Authorization Criteria: Member is NOT on concurrent or dual therapy with another potassium binder

Exclusion: concurrent potassium binder therapy disqualifies approval

Initial Authorization Criteria: Member has been counseled to follow a low potassium diet (≤ 3 g/day)≤ 3 g/day

Initial Authorization Criteria: If clinically appropriate, medications known to cause hyperkalemia have been discontinued or reduced to the lowest effective dose with documentation if no alternative exists

Examples include ACE inhibitors, ARBs, aldosterone antagonists; submit documentation if continued at reduced dose

Member on concurrent or dual therapy with another potassium binder is excluded from approval. The prescriber must attest that the member is NOT on concurrent or dual therapy with another potassium binder; requests lacking this attestation may be denied.

Diagnosis and laboratory coding

Diagnosis codesICD-10

ICD code (member provided)

Diagnosis ICD code as applicable (to be supplied by prescriber)

Baseline serum potassium threshold — inv-04

Baseline serum potassium threshold>5.0 mEq/L

Context for thresholdProvider must submit laboratory documentation of serum potassium levels supporting hyperkalemia (baseline serum potassium >5.0 mEq/L).

Use in determinationsBaseline >5.0 mEq/L is required for initial authorization for potassium binders (Lokelma, Veltassa).

Provider actions and documentation requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Lokelma (sodium zirconium cyclosilicate) and Veltassa (patiromer). Initial and reauthorization approvals are for up to 12 months.

Drugs: Lokelma®, Veltassa®
Initial Authorization: up to 12 months
Reauthorization: up to 12 months

Step Therapy

Step Therapy / Diuretic Trial

If clinically appropriate, the prescriber must attest that the member has tried and failed loop or thiazide diuretic therapy for potassium removal before initiating a potassium binder.

Prescriber attestation of prior loop or thiazide diuretic trial when clinically appropriate

Documentation Required

Required Clinical Documentation

Submit laboratory documentation of serum potassium levels to support the diagnosis and therapy. For initial requests provide baseline serum potassium >5.0 mEq/L. For reauthorization, provide ongoing monitoring and documentation of clinical benefit (e.g., potassium returned to normal or significant decrease from baseline). Also include relevant chart notes and diagnostics.

Initial: baseline serum potassium >5.0 mEq/L
Reauthorization: documentation of continued monitoring and clinical benefit (eg, potassium normalization or significant decrease)
Include supporting lab results, diagnostics, and chart notes

Denial Risk

Submission Requirements and Risk of Delay/Denial

The prescribing physician must sign and clearly print their name on the prior authorization request; preprinted stamps are not valid. If the request form or supporting information is incomplete, incorrect, or illegible, the authorization process may be delayed or denied.

Prescriber signature and printed name required (no preprinted stamps)
Ensure all fields (phone, fax, drug form/strength, dosing, diagnosis, ICD code, weight, dates) are complete and legible
Incomplete/incorrect/illegible submissions can delay or result in denial

Background and clinical context

Chronic hyperkalemia is elevated serum potassium that requires management to reduce the risk of cardiac and neuromuscular complications. Oral potassium binders such as sodium zirconium cyclosilicate (Lokelma) and patiromer (Veltassa) are used to lower serum potassium in patients with chronic non‑life‑threatening hyperkalemia when dietary measures and other interventions are insufficient. Management and authorization require documented baseline laboratory evidence (e.g., baseline serum potassium >5.0 mEq/L), monitoring of serum potassium during treatment, and submission of documentation demonstrating clinical benefit for reauthorization.

Key definitions

Definition — inv-10

DefinitionChronic non-life threatening hyperkalemia

Role in policyDiagnosis required for coverage of oral potassium binders (initial authorization).

Related requirementProvider must submit laboratory documentation (baseline serum potassium >5.0 mEq/L) when diagnosing chronic non-life threatening hyperkalemia.

Initial authorization criteria

Initial Authorization

Initial Authorization (12 months)

Initial therapy requirements: Member ≥18 years; diagnosis of chronic non-life threatening hyperkalemia; baseline serum potassium >5.0 mEq/L documented; attempted trial of loop or thiazide diuretic if clinically appropriate; not on concurrent potassium binder therapy; counseling on low potassium diet (≤ 3 g/day); attempt discontinuation or dose reduction of medications known to cause hyperkalemia if clinically appropriate with documentation.see nodes

Initial authorization duration: 12 months; all criteria must be met and documentation supplied

Reauthorization / continuation criteria

Reauthorization

Continuation requirements: Provider attests serum potassium levels continue to be monitored; Provider has submitted documentation to support clinical benefit from treatment (e.g., potassium level returned to normal or significant decrease from baseline), and member continues to require treatment for hyperkalemia.see nodes

Reauthorization period: 12 months; all criteria must be met and supporting labs/chart notes must be provided

Step therapy requirements

Step	Requirement
1	Provider attests, if clinically appropriate, member has tried and failed loop or thiazide diuretic therapy for potassium removal