Nephrology -Xphozah Prior Authorization Policy
Defines prior authorization requirements and medical necessity criteria for coverage of Xphozah (tenapanor) for adults with hyperphosphatemia in chronic kidney disease on maintenance dialysis. Specifies required prescriber specialty, laboratory thresholds, prior therapy attempts/contraindications, approval duration, and non-covered uses.
Policy review dated 07/23/2025 with no stated criteria changes in history.
Coverage Summary
Scope: Defines prior authorization requirements and medical necessity criteria for coverage of Xphozah (tenapanor) for adults with hyperphosphatemia in chronic kidney disease on maintenance dialysis. Coverage stance: Covered with criteria. Approval duration: Approve for 1 year. Intended population: adults (≥18 years) with CKD on maintenance dialysis (≥3 months) with hyperphosphatemia meeting specified serum phosphate thresholds and prior therapy/contraindication requirements. Background context: efficacy demonstrated in three pivotal trials (PHREEDOM, BLOCK, and AMPLIFY) showing statistically significant reductions in serum phosphate in patients on maintenance dialysis for ≥3 months.
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