CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Finerenone (Kerendia) — Coverage Criteria for CKD with Type 2 Diabetes

Policy governs authorization and coverage criteria for finerenone (Kerendia) for adults with chronic kidney disease associated with type 2 diabetes for Neighborhood Health Plan of Rhode Island Medicaid members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyFinerenone (Kerendia) — Coverage Criteria for CKD with Type 2 Diabetes

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2022

Next Review DateN/A

Key ActionObtain prior authorization with documentation of age ≥18, CKD with type 2 diabetes, baseline labs (eGFR, UACR, serum potassium), specialist involvement, trial of an SGLT2 inhibitor with renal benefit (or documented intolerance), and use of ACEi/ARB unless contraindicated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization duration

≥18minimum patient age

≥230 mg/gUACR requirement

≥25eGFR requirement

<5.0Serum K+ requirement

1 tab/dayquantity limit

Coverage Criteria for Finerenone (Kerendia)

inv-01: Initial Authorization

Covered when ALL of the following are met

Initial approval criteria

Baseline labs: Urine albumin-to-creatinine ratio (UACR) >= 230 mg/g; AND estimated glomerular filtration rate (eGFR) >= 25 mL/min/1.73 m2; AND serum potassium < 5.0 mEq/L
Concomitant or prior therapy: Documentation that patient is currently receiving a maximally tolerated dose of an SGLT2 inhibitor with renal benefit (e.g., dapagliflozin) OR has documented intolerance/contraindication to an SGLT2 inhibitor; AND documentation that patient is currently receiving a maximally tolerated and stabilized dose of an ACE inhibitor or an ARB unless all agents in these classes are contraindicated

Authorization duration: When all criteria above are met, prior authorization may be granted for 12 months.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyFinerenone (Kerendia) — Coverage Criteria for CKD with Type 2 Diabetes

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2022

Next Review DateN/A

SourceLink

On This Page

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.

Provider Requirements and Authorization Process

Prior Authorization

Prior authorization — baseline criteria and 12-month authorization duration

Prior authorization is required. Authorizations are granted for up to 12 months when baseline criteria are met. Prescribers should ensure documentation supports the diagnosis, specialist involvement (or consultation), and baseline laboratory values before submitting a request.

Authorization duration: up to 12 months
Prescriber specialty: cardiology, endocrinology, or nephrology (or documented consultation)

Step Therapy

SGLT2 inhibitor trial requirement

Member must be currently receiving a maximally tolerated dose of an SGLT2 inhibitor with demonstrated renal benefit (e.g., dapagliflozin [Farxiga]) prior to approval. If the member has a documented intolerance or contraindication to SGLT2 inhibitors, document the clinical reason to support an exception.

Example agents with renal benefit: dapagliflozin (Farxiga)
If intolerance/contraindication to SGLT2, provide documentation of clinical rationale

Documentation Required

Required baseline documentation — diagnosis, prescriber specialty or consultation, and other documentation items

Required baseline documentation includes: documented diagnosis of CKD associated with type 2 diabetes, prescriber specialty or documentation of specialist consultation, baseline labs demonstrating eGFR and urine albumin-to-creatinine ratio (UACR), and serum potassium.

Diagnosis: chronic kidney disease associated with type 2 diabetes
Prescriber: cardiologist, endocrinologist, or nephrologist — or consult note
Baseline labs: eGFR (≥ 25 mL/min/1.73 m2 as specified), UACR (≥ 230 mg/g as specified), serum potassium (< 5.0 mEq/L)
Concomitant therapy: documentation of maximally tolerated/stabilized ACE inhibitor or ARB unless contraindicated

Denial Risk

Failure to meet baseline approval criteria — denial conditions and next steps

If baseline approval criteria are not met — for example, missing documentation of SGLT2 inhibitor trial or specialist involvement, or absent baseline labs — the request will be denied. Denials should include instructions for next steps and what documentation is needed to appeal or resubmit.

Common denial triggers: no documentation of current maximally tolerated SGLT2 inhibitor with renal benefit, missing eGFR/UACR/serum potassium values, or lack of specialist prescriber/consultation
Next steps after denial: provide the missing documentation (labs, therapy history, specialist consult) and resubmit for reconsideration

Background

Finerenone (Kerendia) is indicated for adults with chronic kidney disease associated with type 2 diabetes to reduce the risk of kidney disease progression and cardiovascular events. Prior authorization may be granted for up to 12 months when all baseline criteria are met, including: patient age ≥ 18 years; documented CKD with type 2 diabetes; prescription by or in consultation with a cardiologist, endocrinologist, or nephrologist; baseline UACR ≥ 230 mg/g; baseline eGFR ≥ 25 mL/min/1.73 m2; baseline serum potassium 5.0 mEq/L; documentation of current use of a maximally tolerated SGLT2 inhibitor with renal benefit (e.g., dapagliflozin) or documented intolerance/contraindication to such; and documentation of maximally tolerated/stabilized ACE inhibitor or ARB therapy unless contraindicated.

Definitions

inv-12: UACR — Urine albumin-to-creatinine ratio

TermUACR (Urine albumin-to-creatinine ratio)

Use in policyBaseline UACR must be >= 230 mg/g for initial authorization

Measurement sampleUrine

inv-13: eGFR — Estimated glomerular filtration rate

TermeGFR (Estimated glomerular filtration rate)

Use in policyBaseline eGFR must be >= 25 mL/min/1.73m2 for initial authorization

Clinical relevanceUsed to assess renal function prior to initiating finerenone

inv-14: SGLT2 inhibitor with renal benefit — example: dapagliflozin (Farxiga)

DefinitionSGLT2 inhibitor with renal benefit (example)

Example agentDapagliflozin (Farxiga)

Policy usePatient must be on a maximally tolerated SGLT2 inhibitor with renal benefit or have documented intolerance/contraindication

OpenPayer

Finerenone (Kerendia) — Coverage Criteria for CKD with Type 2 Diabetes

Coverage Criteria for Finerenone (Kerendia)

Key Clinical Thresholds and Coding

Provider Requirements and Authorization Process

Background

Definitions