CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Prior authorization criteria — Finerenone (Kerendia) for CKD associated with type 2 diabetes

Prior authorization criteria for coverage of Kerendia (finerenone) for adults with chronic kidney disease associated with type 2 diabetes, specifying required background ACEi/ARB therapy or intolerance/contraindication. Affects prescribers requesting Kerendia for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPrior authorization criteria — Finerenone (Kerendia) for CKD associated with T2D

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization showing diagnosis of CKD with T2D and documentation of current maximally tolerated ACEi/ARB use or intolerance/contraindication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1FDA-approved indication described

3Key coverage decision nodes

1Reference list included

Coverage Criteria for Finerenone (Kerendia)

Initial prior authorization criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage for finerenone (Kerendia) requires that the member have chronic kidney disease (CKD) associated with type 2 diabetes (T2D) and meet one of the ACEi/ARB-related conditions. Specifically, the patient must be currently receiving a maximally tolerated dose of an ACE inhibitor (ACEi) or an angiotensin receptor blocker (ARB), OR have documented intolerance to an ACEi or ARB, OR have a documented contraindication that would prohibit a trial of an ACEi or ARB. These ACEi/ARB requirements are part of the prior authorization criteria and must be supported by clinical documentation with the authorization request.

Provider Requirements and Authorization Process

Prior Authorization

Prior Authorization Required

Prior authorization is required for coverage. Requests must demonstrate the member meets the clinical coverage criteria for chronic kidney disease (CKD) associated with type 2 diabetes (T2D). Incomplete requests lacking required clinical documentation may be denied.

Prior authorization required before drug dispensation
Coverage contingent on meeting CKD with T2D criteria

Step Therapy

ACEi/ARB Step Therapy Requirement

Requests must document that the patient is currently receiving a maximally tolerated dose of an angiotensin‑converting enzyme inhibitor (ACEi) or an angiotensin receptor blocker (ARB). If the patient is unable to tolerate an ACEi or ARB, documentation of the intolerance is required. If an ACEi/ARB trial is medically contraindicated, provide documentation of the contraindication.

Current or prior trial of maximally tolerated ACEi or ARB required
If intolerance to ACEi/ARB, include clinical documentation describing adverse reaction(s) and why therapy cannot be continued
If ACEi/ARB are contraindicated, document the specific contraindication

Documentation Required

Required Documentation

Provide documentation supporting the diagnosis of CKD associated with type 2 diabetes (T2D) and evidence of ACEi/ARB therapy status or intolerance/contraindication. Required documentation may include relevant problem list entries, diagnostic test results, medication history, and clinician notes describing intolerance or contraindication.

Diagnosis of CKD with T2D (e.g., ICD-10 diagnosis, clinician note)
Medication history showing current or prior ACEi/ARB use and dosing, or documentation of intolerance
Clinical notes documenting any contraindication to ACEi/ARB trial

Denial Risk

Denial Triggers

Requests missing documentation of CKD with T2D or lacking evidence of a current/prior maximally tolerated ACEi or ARB trial — or missing acceptable documentation of ACEi/ARB intolerance/contraindication — are subject to denial.

Missing CKD with T2D diagnosis documentation may result in denial
Absence of ACEi/ARB trial evidence or missing intolerance/contraindication documentation may result in denial

Key Definitions

Definition: CKD associated with T2D

Population (per FDA-approved indication)Adults with chronic kidney disease (CKD) associated with type 2 diabetes (T2D)

Clinical goalTo reduce risk of sustained eGFR decline, end-stage kidney disease, cardiovascular death, nonfatal myocardial infarction, and hospitalization for heart failure

Required diagnosis documentationMedical record must document CKD associated with T2D as the indication for therapy

Definition: Maximally tolerated ACEi/ARB

DefinitionA maximally tolerated ACEi or ARB is the highest dose of an angiotensin‑converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) that the patient can tolerate

Alternate allowanceCoverage also applies if patient has documented intolerance to an ACEi/ARB

Contraindication allowanceCoverage also applies if patient has a documented contraindication that would prohibit a trial of an ACEi/ARB

Clinical and Regulatory Background

Finerenone (brand name Kerendia) is an oral, nonsteroidal selective mineralocorticoid receptor antagonist approved to reduce the risk of sustained decline in estimated glomerular filtration rate (eGFR), progression to end-stage kidney disease, and adverse cardiovascular outcomes in adults with CKD associated with type 2 diabetes. The clinical evidence cited in the policy (including the pivotal trials summarized in the Kerendia package insert and peer-reviewed publications) supports reductions in renal and cardiovascular events in this population.

References and Revision History

References cited in this policy include the Kerendia (finerenone) package insert and key clinical and guideline sources: Lexicomp/AHFS DI and Micromedex for drug information, the KDIGO 2020 Diabetes in CKD guideline, the ADA Standards of Care, and the pivotal New England Journal of Medicine trial reporting finerenone’s effect on CKD outcomes in type 2 diabetes. Source documents and bibliographic entries are listed here for clinical verification and further review.