Lokelma™

Drug - Lokelma™ (sodium zirconium cyclosilicate powder) [AstraZeneca Pharmaceuticals LP]

June 2019

Therapeutic area - Hyperkalemia

Initial approval criteria

Patient must:

• Be ≥ 18 years of age AND
• Have a diagnosis of chronic hyperkalemia AND
• Have had an adequate trial and failure of sodium polystyrene sulfonate
• Initial approval is for 15 days

Renewal criteria

• Continue to meet initial request criteria AND
• Have an absence of treatment-limiting adverse effects (e.g. edema) AND
• Have documented efficacy (e.g., serum potassium levels within normal limits [3.5 to 5 mEq/L])
• Renewal approval is for 15 days

Quantity limits

• Initial request: 19 packets/15 days
• Renewals: 15 packets/15 days

Questions?

MHCP Provider Call Center 651-431-2700 or 800-366-5411