CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Veltassa (patiromer) coverage for hyperkalemia

Defines medical necessity criteria, authorization duration, quantity limits, and continuation criteria for coverage of Veltassa (patiromer) for treatment of hyperkalemia members of Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVeltassa (patiromer) coverage for hyperkalemia

Policy CodePolicy N/A

Change Typeclarified

Effective DateSep 1, 2018

Next Review Date

Key ActionAuthorization may be granted for 12 months only when all specified criteria are documented, including age >=12, hyperkalemia diagnosis with serum K>5 mEq/L, appropriate prescriber, prior interventions attempted, intolerance/failure to loop diuretic and SPS (and Lokelma for ≥18), and non‑concomitant use with Lokelma.

SourceLink

POLICY UPDATE CHANGES

References include Veltassa package insert dated November 2024.

12 monthsAuthorized Coverage Duration

>=12Minimum Age

>5 mEq/LDiagnostic Threshold

>6.5 mEq/LOffending agents threshold

Quantity limits

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Daily Dose Restrictions

Coverage Summary

Veltassa (patiromer) is indicated for the treatment of hyperkalemia. This policy defines medical necessity criteria for coverage of Veltassa and allows an authorization of 12 months when specified criteria are met, including age, diagnosis, prescriber requirements, prior interventions, and quantity limits.

Coverage is for patients 12 years and older with a documented diagnosis of hyperkalemia defined as serum potassium greater than 5 mEq/L. Prior attempts at conservative measures and documented failure, contraindication, or intolerance to specified potassium-lowering interventions are required before approval. Quantity limits are: Veltassa 1 g: 4 packets per day; Veltassa 8.4 g, 16.8 g, 25.2 g: 1 packet per day.

Policy Quick Facts

Authorized Coverage Duration12 months

Minimum Age>= 12 years

Diagnostic ThresholdHyperkalemia >5 mEq/L (serum potassium >5 mEq/L)

Daily Dose RestrictionsVeltassa 1 gm: up to 4 packets/day; Veltassa 8.4, 16.8, 25.2 gm: 1 packet/day

Prescriber RequirementPrescribed by or in consultation with a nephrologist or cardiologist

Prior Intervention RequirementsAttempts at conservative measures (e.g., discontinue NSAIDs or reduce/discontinue offending RAAS agents if K>6.5 mEq/L) and failure/intolerance to loop diuretic and short-term sodium polystyrene sulfonate

Medical Necessity Criteria

Initial Authorization (12 months)

An authorization of 12 months may be granted when all the following criteria are met:

ALL of the following

Patient is 12 years old or older
Patient has a diagnosis of hyperkalemia (serum potassium greater than 5 mEq/L)> 5 mEq/L
Prescriber
- Prescribed by a nephrologist
- Prescribed by a cardiologist

Not Covered / Experimental

Concomitant use of Veltassa with Lokelma is not allowed per the criteria (patient will not use Veltassa concomitantly with Lokelma). No other experimental or unproven uses or specific exclusions beyond contraindications (e.g., gastrointestinal motility disorder) are specified in the brief.

Coding

Drug (NDC unspecified in document)NDCCovered

No codes listed

Provider Actions & Billing

Prior Authorization

Prior authorization required for Veltassa

Authorization may be granted for 12 months only when all specified criteria are documented: patient age 12 years or older; diagnosis of hyperkalemia with serum potassium greater than 5 mEq/L; medication prescribed by or in consultation with a nephrologist or cardiologist; prior interventions attempted (e.g., discontinuation of NSAIDs or dose reduction/discontinuation of offending agents when K>6.5 mEq/L); documented failure, contraindication, or intolerance to a loop diuretic and short-term sodium polystyrene sulfonate; and Veltassa will not be used concomitantly with Lokelma. Apply these criteria for a 12-month authorization.

Documentation Required

Document prior interventions and failures

Document attempts at discontinuation of NSAIDs or dose reduction/discontinuation of offending RAAS agents (e.g., ACE inhibitors, ARBs, aldosterone antagonists) when applicable (dose reduction/discontinuation indicated if serum potassium is greater than 6.5 mEq/L). Also document failures, contraindications, or intolerances to a loop diuretic and short-term therapy with sodium polystyrene sulfonate, and for patients 18 years of age and older document failure, contraindication, or intolerance to Lokelma.

Background, Evidence & Definitions

Veltassa is indicated to lower serum potassium in patients with hyperkalemia. The policy requires that conservative measures and alternative therapies be attempted prior to approval — for example discontinuation of NSAIDs or dose reduction/discontinuation of offending agents (ACE inhibitors, ARBs, or aldosterone antagonists) when serum potassium is > 6.5 mEq/L — and documented failure, contraindication, or intolerance to a loop diuretic and short-term sodium polystyrene sulfonate. For patients 18 years and older, failure/contraindication/intolerance to Lokelma is also required before approval.

Source	Details
Veltassa [package insert], Relypsa, Inc.; November 2024
Reference lists Veltassa (patiromer) package insert as Relypsa, Inc.; November 2024 (policy reference).

Definitions

HyperkalemiaSerum potassium greater than 5 mEq/L as used in this policy.

Revision History

2018-07review

Policy reviewed (listed review date 7/2018).

2019-07review

Policy reviewed (listed review date 7/2019).

2020-08review

Policy reviewed (listed review date 8/2020).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVeltassa (patiromer) coverage for hyperkalemia

Policy CodePolicy N/A

Change Typeclarified

Effective DateSep 1, 2018

Next Review Date

SourceLink

On This Page

Prescribed in consultation with a nephrologist

Prescribed in consultation with a cardiologist

Patient does not have a diagnosis of a gastrointestinal motility disorder

Prior interventions

Discontinuation of NSAIDs
Dose reduction or discontinuation of offending agents (e.g., ACE inhibitors, ARBs, aldosterone antagonists) if serum potassium is greater than 6.5 mEq/L> 6.5 mEq/L

Patient has experienced a failure, contraindication or intolerance to a loop diuretic, short term therapy with sodium polystyrene sulfonate

Required prior failure/intolerance to both a loop diuretic and short-term SPS therapy (per wording)

If the patient is 18 years of age and older they have experienced a failure, contraindication, or intolerance to Lokelma

Applies only to patients >= 18 years

Patient will not use Veltassa concomitantly with Lokelma

Continuation of Therapy (12 months)

Authorization of 12 months may be granted for members who meet all of the following:

ALL of the following

Member is tolerating treatment
Documentation of a positive clinical response with no severe side effects (example: hypokalemia)
Member does not have a diagnosis of a gastrointestinal motility disorder

Documentation Required

Monitor for tolerability and clinical response for continuation

For continuation of therapy, document that the member is tolerating Veltassa, has a positive clinical response, and has not experienced severe side effects (for example, hypokalemia). Also ensure the member does not have a diagnosis of a gastrointestinal motility disorder.

Billing Rule

Quantity limits

Apply quantity limits at claim adjudication: Veltassa 1 g formulation — up to 4 packets per day; Veltassa 8.4 g, 16.8 g, and 25.2 g formulations — 1 packet per day.

2018-09-01effective_date

Policy effective date 2018-09-01.

2024-11reference_updateLatest

Package insert citation updated: Veltassa [package insert], Relypsa, Inc.; November 2024.