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Kerendia (finerenone) — Coverage Criteria
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This policy governs prior authorization and medical necessity criteria for coverage of Kerendia (finerenone) for adults with chronic kidney disease and type 2 diabetes or heart failure, per Blue Cross Blue Shield - Iowa.
Reviewed and revised in June 2026 with a current effective date of August 5, 2026.
Coverage and Medical Necessity Criteria
Initial Therapy — CKD and T2DM
Covered when ALL of the following are met for CKD with T2DM (Initial Approval):
CKD and T2DM Initial - Lab criteria
- a: Urinary albumin-to-creatinine ratio (UACR) >= 30 mg/g (>= 3 mg/mmol).>= 30 mg/g (>= 3 mg/mmol)
- b: An estimated glomerular filtration rate (eGFR) >= 25 ml/min/1.73 m2.>= 25 ml/min/1.73 m2
- c: Serum potassium <= 5 mEq/L.<= 5 mEq/L
Initial Therapy — Heart Failure
Covered when ALL of the following are met for Heart Failure (Initial Approval):
HF Initial - Lab criteria
- a: An eGFR >= 25 ml/min/1.73 m2.>= 25 ml/min/1.73 m2
- b: A serum potassium level <= 5 mEq/L.<= 5 mEq/L
Continuation Therapy — CKD and T2DM
Covered when ALL of the following are met for CKD with T2DM (Continuation):
Approval duration: 12 months
Continuation Therapy — Heart Failure
Covered when ALL of the following are met for Heart Failure (Continuation):
Approval duration: 12 months
Initial coverage criteria (Kerendia for CKD with T2D)
Covered when ALL of the following are met
Indication aligns with FDA labeling and clinical rationale
Policy states coverage will be considered when concomitant therapy or documented intolerance/contraindication exists
Guideline-referenced threshold for ns-MRA use
Members who fail to meet the specific clinical criteria detailed above are considered not eligible for coverage. This includes members who do not have the required diagnosis, do not meet the laboratory thresholds (for example, eGFR ≥ 25 ml/min/1.73 m2 or the applicable serum potassium thresholds), or who lack documentation of required concomitant therapy or documented intolerance/contraindication. Members receiving Kerendia as samples or through the manufacturer's patient assistance program must still meet the criteria for initial approval to be covered.
None explicitly listed in this section of the policy.
Kerendia is considered not medically necessary for members who do not meet the specified initial or continuation approval criteria set forth in this policy. This determination applies when required diagnostic criteria, age, laboratory thresholds, or documentation of background therapy (or documented intolerance/contraindication) are not provided.
Coverage consideration for Kerendia assumes either concomitant use of an ACE inhibitor or ARB and an SGLT2 inhibitor or clear documentation of intolerance or contraindication to those agents. In the absence of documentation showing the patient is receiving these concomitant therapies or has an intolerance/contraindication, coverage may be denied. Providers should therefore document current background therapies or the clinical rationale for not using them.
Billing and Clinical Thresholds
| CPT (general) | Appropriate CPT codes to report provider services as applicable (document references CPT use but does not list specific codes) |
| HCPCS (Alpha Numeric level II) | Use appropriate HCPCS level II codes where applicable (document references HCPCS use but does not list specific codes) |
| Revenue | Use appropriate revenue codes as applicable |
| ICD-10 | Use appropriate ICD diagnostic codes as applicable |
| NDC | Drug NDC codes for Kerendia (finerenone) as applicable |
Prior Authorization and Documentation Requirements
Prior authorization required
Prior authorization is required for Kerendia; approvals are granted only when the submitted request meets the applicable initial or continuation clinical criteria (diagnosis, age, eGFR, serum potassium, concomitant ACEi/ARB status, and UACR for CKD with T2D).
Prior authorization must confirm indication and background therapy
Submit a prior authorization that documents the patient has CKD associated with type 2 diabetes and includes verification of concomitant ACEi/ARB and SGLT2 use or documented intolerance/contraindication; include appropriate billing codes (CPT/HCPCS/ICD or NDC as applicable).
Document ACEi/ARB status and SGLT2 context
Document that the member is receiving a maximally tolerated dose of an ACE inhibitor or ARB, or that there is an intolerance, allergy, or contraindication to ACEi/ARB; policy references use of Kerendia alongside SGLT2 inhibitor therapy per clinical guidance.
- For CKD with T2D initial and continuation criteria, ACEi/ARB status (maximally tolerated or intolerance/contraindication) is required (see criteria).
- Clinical rationale supports addition of ns‑MRA when albuminuria persists despite maximal ACEi/ARB and in the context of SGLT2 therapy.
Document persistent albuminuria and SGLT2 context
When albuminuria persists despite a maximally tolerated ACEi or ARB, document current SGLT2 therapy or reason it is not used; policy supports Kerendia use in patients with persistent albuminuria despite ACEi/ARB and in the context of SGLT2 therapy.
- For CKD with T2D initial approval, record UACR ≥ 30 mg/g (≥3 mg/mmol) and eGFR ≥ 25 ml/min/1.73 m2.
- State whether the patient is taking an SGLT2 inhibitor or provide documentation of intolerance/contraindication if not.
Verify member benefits and contract applicability
Verify individual member benefits and applicable contract language at the time of service; exclusions, limitations, or exceptions may apply and benefits may vary by contract.
- Benefit verification is required before assuming coverage; Wellmark determines medical necessity only if the benefit exists and no contract exclusions apply.
Documentation: diagnosis, baseline therapies, labs, and intolerance/contraindication
Include documentation of the diagnosis (CKD associated with T2D or heart failure as applicable), baseline therapies (current ACEi/ARB and SGLT2 inhibitor), or clear documentation of intolerance/contraindication to those agents; provide relevant labs (UACR, eGFR, serum potassium) aligned to the criteria.
- For CKD with T2D initial approval: UACR ≥ 30 mg/g (≥3 mg/mmol), eGFR ≥ 25 ml/min/1.73 m2, and serum potassium ≤ 5 mEq/L.
- For continuation: document clinical improvement and serum potassium ≤ 5.5 mEq/L.
- Use appropriate CPT/HCPCS/ICD codes when submitting claims.
Denial risk when criteria are not met
Kerendia will be considered not medically necessary and may be denied when the member does not meet the specified initial or continuation criteria (including diagnosis, age, required lab thresholds, or documented background therapy/intolerance).
- Members receiving samples or manufacturer assistance must also meet initial approval criteria.
- Absence of documentation of ACEi/ARB and SGLT2 use (or intolerance/contraindication) may lead to non-coverage.
Coverage when concomitant therapy present or intolerance/contraindication documented
Coverage may be granted when the patient is receiving concomitant ACEi/ARB and SGLT2 therapy or when there is documented intolerance or contraindication to those agents; include documentation of the intolerance/contraindication or current concomitant therapy in the prior authorization.
- Policy language: coverage will be considered in patients receiving concomitant therapy with, who have experienced intolerance to, or have a contraindication to an ACEi or ARB and an SGLT2 inhibitor.
- Provide clear documentation of concomitant medications or clinical rationale for withholding them.
Drug Background and Evidence Summary
Kerendia (finerenone) is a selective nonsteroidal mineralocorticoid receptor antagonist (ns-MRA) indicated to reduce the risk of sustained eGFR decline, end-stage kidney disease, and cardiovascular events in adults with chronic kidney disease associated with type 2 diabetes. Phase 3 trials (FIDELIO-DKD and FIGARO-DKD) demonstrated kidney and cardiovascular benefits when finerenone was added to standard therapy, and guideline consensus recommends ns‑MRA use in patients with T2D and CKD who have eGFR ≥ 25 ml/min/1.73 m2, normal serum potassium, and persistent albuminuria despite maximally tolerated ACEi or ARB therapy.
Key Definitions and Terms
Policy Revision History
Policy current effective date updated to August 5, 2026 after June 2026 review and revision.
Policy was reviewed and revised in June 2026 (per policy history).
Policy originally became effective August 1, 2023.
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