CurrentCignaPolicy N/A

Potassium Binders - Lokelma Drug Quantity Management Policy - Per Rx

Defines per-prescription maximum quantities and authorization criteria for Lokelma packets for Cigna-administered health benefit plans; affects providers and pharmacists requesting dispenses for members.

Policy Summary

PayerCigna

PolicyPotassium Binders - Lokelma Drug Quantity Management Policy - Per Rx

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateSep 27, 2024

Key ActionQuantity management limits apply at point of service; request exceptions per the policy and approvals are for one year.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30Retail max per Rx (5g & 10g)

90Home delivery max per Rx (5g & 10g)

90Retail when maintenance 15 g/day

270Home delivery when maintenance 15 g/day

34One-time retail initiation override (10g)

Policy Summary

PayerCigna

PolicyPotassium Binders - Lokelma Drug Quantity Management Policy - Per Rx

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateSep 27, 2024

Key ActionQuantity management limits apply at point of service; request exceptions per the policy and approvals are for one year.

SourceLink

On This Page

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Coverage and Drug Quantity Management Criteria

Drug Quantity Limits and Exception Criteria

Lokelma packets are covered as medically necessary when the Drug Quantity Management criteria below are met; any other exception is considered not medically necessary.

Retail/Home Delivery general limits: Retail maximum per Rx = 30 packets for both 5 g and 10 g packets; Home Delivery maximum per Rx = 90 packets for both 5 g and 10 g packets.30 retail / 90 home

5 g packet exception for maintenance 15 g/day: If the patient requires a maintenance dose of 15 grams daily, approve 90 packets per dispensing at retail and 270 packets per dispensing at home delivery.90 retail / 270 home

Approvals are provided for one year unless otherwise noted.

10 g packet initiation override: If the patient is initiating therapy with Lokelma, approve a one-time override for the requested quantity, not to exceed 34 packets at retail and 94 packets at home delivery.34 retail / 94 home

One-time override for initiation.

Lokelma packets are covered as medically necessary only when the Drug Quantity Management criteria in this policy are met. Any exception not meeting the specified quantity criteria is considered not medically necessary.

Requests that exceed the stated maximum quantities per prescription without meeting the listed exception criteria will be considered not medically necessary. Coverage is limited to the maximum per‑Rx quantities specified in the policy unless an approved exception applies.

Provider Actions, Enforcement, and Approval Duration

Prior Authorization

Provider Action Required

Quantity management limits apply at the point of service; if the Drug Quantity Management rule is not met for the requested medication at the point of service, coverage will be determined by the policy criteria. All approvals are provided for 1 year in duration, unless otherwise noted.

Quantity limits enforced at point of sale; exceptions require meeting policy criteria
Approvals are valid for 1 year unless otherwise specified

Documentation Required

Provider Reminder

Providers should confirm applicable Drug Quantity Management limits when submitting prescriptions for Lokelma and follow the policy criteria for exceptions. Documentation supporting the clinical need for doses or quantities beyond the point-of-service limit should be provided with authorization requests.

Background and Clinical Context

Lokelma (sodium zirconium cyclosilicate) is a potassium binder indicated for the treatment of hyperkalemia in adults. The policy’s Drug Quantity Management program defines per‑prescription maximums to support dose titration and dose consolidation for both the 5 g and 10 g packet presentations. Standard maximums are 30 packets per Rx at retail and 90 packets per Rx for home delivery, with specified exception pathways for maintenance dosing and one‑time initiation overrides as detailed in this policy.

Definitions and Dosing Summary

Lokelma — key fact

IndicationPotassium binder indicated for treatment of hyperkalemia in adults.

Dosing summary

Recommended starting (acute) dose10 grams orally three times a day for up to 48 hours.

Typical maintenance dose10 grams once daily; maintenance range 5 grams every other day to 15 grams once daily.

Titration guidanceMay be titrated in 5 gram increments at intervals of 1 week or longer based on serum potassium; decrease or discontinue if serum potassium is below target.

Dialysis-specific dosingFor chronic hemodialysis: start 5 grams once daily on non-dialysis days; if pre-dialysis K+ >6.5 mEq/L, may start 10 grams once daily on non-dialysis days.

Per-Rx Quantity Limits and Overrides

Quantity limit — 5 g packets (retail)

Retail maximum per Rx (5 g packets)30 packets

Quantity limit — 5 g packets (home delivery)

Home delivery maximum per Rx (5 g packets)90 packets

Quantity limit — 10 g packets (retail)

Retail maximum per Rx (10 g packets)30 packets

Quantity limit — 10 g packets (home delivery)

Home delivery maximum per Rx (10 g packets)