CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Generic Phosphate Binders (sevelamer carbonate packet, lanthanum chewable tablet)

Defines coverage and step therapy requirements for sevelamer carbonate packets and lanthanum chewable tablets, including required prior trials, prior paid claim supply and coverage duration.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyGeneric Phosphate Binders (sevelamer carbonate packet, lanthanum chewable tablet)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date03/01/2020

Next Review DateN/A

Key ActionObtain documentation showing trial and inadequate response or intolerance to calcium acetate 667 mg capsule AND sevelamer carbonate 800 mg tablet, plus at least one paid claim of a ≥10-day supply within the last 365 days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthscoverage duration

10-daymin prior paid supply

365 dayslookback period

2019–2025review history

Coverage Criteria

Initial coverage criteria

Covered when ALL of the following are met

Step therapy prerequisites: Member has trialed and experienced an inadequate treatment response or intolerance to formulary calcium acetate 667mg capsule AND sevelamer carbonate 800mg tablet

Required medical information as stated in policy

Evidence of prior dispensing: At least one paid claim of at least a 10-day supply within the last 365 days for calcium acetate 667mg capsule AND sevelamer carbonate 800mg tablet (for formulary lanthanum chewable tablet or sevelamer packet to pay)>=10-day supply; <=365 days

Grandfathering of target drug applies

Coverage duration: If criteria met, coverage duration is 12 months

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyGeneric Phosphate Binders (sevelamer carbonate packet, lanthanum chewable tablet)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date03/01/2020

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.

Covered Products and Coding

Covered drug products and required comparatorsNDC | Medication descriptions

calcium acetate 667 mg capsule	Formulary required trial agent (dose as stated)
sevelamer carbonate 800 mg tablet	Formulary required trial agent (dose as stated)
sevelamer carbonate packet (Renvela)	Target drug formulation
lanthanum chewable tablet (Fosrenol)	Target drug formulation

inv-04: Minimum prior paid claim supply

Minimum prior paid claim supplyAt least one paid claim of at least a 10‑day supply for each required trial agent (calcium acetate 667 mg capsule AND sevelamer carbonate 800 mg tablet)

Applies toFormulary lanthanum chewable tablet and sevelamer carbonate packet as target drugs

GrandfatheringGrandfathering of target drug applies when prior paid‑claim condition is met

inv-05: Lookback period for prior claim

Lookback periodPrior paid claim(s) must be within the last 365 days

Required agents for lookbackCalcium acetate 667 mg capsule AND sevelamer carbonate 800 mg tablet

Combines with supply thresholdLookback period is applied together with the >=10‑day supply requirement to satisfy step‑therapy coding logic

Provider Actions / Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization (step therapy) is required. Coverage for formulary lanthanum chewable tablet (Fosrenol) or sevelamer carbonate packet (Renvela) will be approved only when there is documentation that the member has trialed and experienced an inadequate treatment response or intolerance to formulary calcium acetate 667 mg capsule and sevelamer carbonate 800 mg tablet. For step-therapy coding logic, the formulary lanthanum chewable tablet or sevelamer packet will pay if there is at least one paid claim of at least a 10-day supply within the last 365 days for calcium acetate 667 mg capsule and sevelamer carbonate 800 mg tablet. Coverage duration when approved: 12 months. Note: investigational use is not covered.

Step therapy prior authorization required: trial and inadequate response or intolerance to calcium acetate 667 mg capsule and sevelamer carbonate 800 mg tablet
Formulary lanthanum chewable tablet or sevelamer packet requires prior paid claims showing at least a 10-day supply of calcium acetate 667 mg and sevelamer carbonate 800 mg within the last 365 days
Required documentation: evidence of trial and inadequate response or intolerance to calcium acetate 667 mg capsule AND sevelamer carbonate 800 mg tablet
Coverage duration when approved: 12 months

Background

Phosphate binders addressed by this policy include sevelamer carbonate packet (Renvela) and lanthanum chewable tablet (Fosrenol). These agents are used to manage hyperphosphatemia, commonly in patients with chronic kidney disease.

For coverage of these non‑formulary formulations, the policy requires step‑therapy evidence that the member has trialed and had an inadequate treatment response or intolerance to formulary first‑line agents: calcium acetate 667 mg capsule and sevelamer carbonate 800 mg tablet. Additionally, coding logic requires at least one paid claim for a minimum of a 10‑day supply of both calcium acetate 667 mg capsule and sevelamer carbonate 800 mg tablet within the prior 365 days for the lanthanum chewable tablet or sevelamer packet to pay (grandfathering of the target drug applies). When criteria are met, authorized coverage duration is 12 months.

OpenPayer

Generic Phosphate Binders (sevelamer carbonate packet, lanthanum chewable tablet)

Coverage Criteria

Covered Products and Coding

Provider Actions / Prior Authorization

Background

Definitions / Investigational Use