CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Patiromer (Veltassa) for hyperkalemia — Coverage Criteria

Policy governs authorization, continuation, quantity limits, and coverage duration for patiromer (Veltassa) to treat hyperkalemia for Neighborhood Health Plan of Rhode Island Medicaid members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPatiromer (Veltassa) for hyperkalemia — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for up to 12 months when member is ≥12 years, has serum potassium >5 mEq/L, is under nephrology/cardiology care, lacks GI motility disorder, and has failed or cannot tolerate listed therapies.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization / coverage duration

≥12minimum age

>5 mEq/Ldiagnostic threshold

4 pkt / 1 g; 1 pkt / otherquantity limits

Coverage Criteria for Patiromer (Veltassa)

Initial Therapy

Authorization of 12 months may be granted when ALL of the following are met:

Initial Approval: Patient is 12 years old or older; AND medication is prescribed by, or in consultation with, a nephrologist or cardiologist; AND patient has a diagnosis of hyperkalemia (serum potassium greater than 5 mEq/L); AND patient does not have a diagnosis of a gastrointestinal motility disorder; AND attempts to manage hyperkalemia with other interventions (e.g., discontinuation of NSAIDs, dose reduction or discontinuation of offending agents such as ACE inhibitors, ARBs, or aldosterone antagonists when serum potassium > 6.5 mEq/L) have been made; AND patient has experienced failure, contraindication, or intolerance to a diuretic and short-term sodium polystyrene sulfonate; AND for patients 18 years of age and older, patient has experienced failure, contraindication, or intolerance to Lokelma; AND patient will not use Veltassa concomitantly with Lokelma.

Wording follows source document ordering and content.

Continuation Therapy

Authorization of 12 months may be granted for continuation when ALL of the following are met:

Continuation of Therapy:

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPatiromer (Veltassa) for hyperkalemia — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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The policy does not list additional specialty requirements beyond the prescribing or consultative involvement of a nephrologist or cardiologist, nor does it specify stepwise timing requirements beyond documented failure, contraindication, or intolerance to the listed interventions. For initial approval the provider must document patient age (≥12 years), a diagnosis of hyperkalemia (serum potassium > 5 mEq/L), absence of a gastrointestinal motility disorder, and prior attempts to control potassium with standard measures (e.g., discontinuation or dose reduction of offending agents, diuretics, and short-term sodium polystyrene sulfonate). For continuation, documentation of tolerance and a positive clinical response without severe adverse effects (for example, hypokalemia) is required.

Provider Requirements, Documentation, and Denial Triggers

Prior Authorization

12-month prior authorization criteria

Authorization of 12 months may be granted when all approval criteria are met, including: patient is 12 years or older; medication is prescribed by or in consultation with a nephrologist or cardiologist; patient has a diagnosis of hyperkalemia (serum potassium greater than 5 mEq/L); patient does not have a diagnosis of a gastrointestinal motility disorder; inability to control hyperkalemia with other interventions as specified; and prior failure/contraindication/intolerance to listed therapies. For continuation, members must be tolerating treatment with documentation of a positive clinical response and no severe side effects (e.g., hypokalemia).

Initial and continuation authorizations are for 12 months when all criteria are documented.

Step Therapy

Step therapy / prior treatment requirements

Prior to approval, document that the member has experienced failure, contraindication, or intolerance to other interventions: a diuretic and short-term sodium polystyrene sulfonate; and for members 18 years or older, failure/contraindication/intolerance to Lokelma (sodium zirconium cyclosilicate).

Failure, contraindication, or intolerance to a diuretic and short-term sodium polystyrene sulfonate is required.
For patients ≥18 years, failure/contraindication/intolerance to Lokelma is required.
Patient must not use Veltassa concomitantly with Lokelma.

Documentation Required

Required documentation

Include clinical documentation of the required approval elements: patient age, diagnosis of hyperkalemia, a recent serum potassium value greater than 5 mEq/L, and the prescribing clinician specialty or documentation of consultation with a nephrologist or cardiologist. Also document absence of a gastrointestinal motility disorder, prior therapies tried (and failures/intolerances/contraindications), and for continuation requests evidence of tolerance and positive clinical response.

Patient age (≥12 years) and diagnosis of hyperkalemia.
Recent serum potassium > 5 mEq/L.
Prescribing clinician is a nephrologist or cardiologist, or documentation of consultation.
Absence of gastrointestinal motility disorder.
Documentation of prior use and failure/contraindication/intolerance to required therapies.
For continuation: evidence of tolerance and positive clinical response with no severe side effects (e.g., hypokalemia).

Denial Risk

Denial triggers — missing required criteria

Requests lacking documentation that the member meets all required criteria may be denied — specifically missing age ≥12, a serum potassium >5 mEq/L, appropriate prescriber specialty or consultation, absence of a GI motility disorder, or documentation of required prior treatments (including Lokelma where applicable).

Missing evidence of patient age ≥12.
No recent serum potassium > 5 mEq/L documented.
Prescriber is not a nephrologist/cardiologist and no consultation is documented.
Diagnosis of a gastrointestinal motility disorder is present.
No documentation of failure/contraindication/intolerance to required prior therapies (diuretic, sodium polystyrene sulfonate, and for adults Lokelma).

Definitions

inv-12: Hyperkalemia — Serum potassium greater than 5 mEq/L as specified for approval.

Definition used in policyHyperkalemia defined as serum potassium greater than 5 mEq/L

Role in criteriaMember must have diagnosis of hyperkalemia (serum K+ > 5 mEq/L) to meet approval

Related management noteThreshold informs need for interventions such as dose reductions if K+ > 6.5 mEq/L

inv-13: Failure/Intolerance/Contraindication to other therapies — Documentation that diuretics, SPS, and for adults Lokelma were ineffective, not tolerated, or contraindicated.

Required documentation of prior therapiesClinical documentation that the patient has experienced failure, contraindication, or intolerance to a diuretic and short-term sodium polystyrene sulfonate

Adult-specific requirementFor patients 18 years of age and older, documentation of failure, contraindication, or intolerance to Lokelma (sodium zirconium cyclosilicate) is required

Concomitant therapy restrictionPatient must not use Veltassa concomitantly with Lokelma

Other interventionsInability to control hyperkalemia with other interventions (e.g., discontinuation of NSAIDs, dose reduction/discontinuation of offending agents) should be documented

OpenPayer

Patiromer (Veltassa) for hyperkalemia — Coverage Criteria

Coverage Criteria for Patiromer (Veltassa)

Key Clinical Thresholds and Eligibility Values

Provider Requirements, Documentation, and Denial Triggers

Background

Definitions