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rivaroxaban oral suspension (brand or generic product) — Cigna

treatment of an acute thromboembolic condition

Initial criteria

  • Patient has been started on Xarelto for the treatment of an acute thromboembolic condition; AND
  • If rivaroxaban oral suspension (brand or generic product) is being requested, approve if the patient meets ONE of the following (i or ii):
  • i. Patient is unable to have Xarelto tablets appropriately administered; OR
  • ii. The prescribed dose cannot be achieved by Xarelto 10 mg, 15 mg, or 20 mg tablets.