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Xarelto (rivaroxaban tablets [generic for 2.5 mg tablet strength only] and oral suspension [generic]) — Cigna

Thromboprophylaxis in a Patient with Congenital Heart Disease

Initial criteria

  • Patient age ≥ 2 years and < 18 years
  • Patient has undergone the Fontan procedure
  • If rivaroxaban oral suspension (brand or generic product) is being requested, patient is unable to have Xarelto tablets appropriately administered OR the prescribed dose cannot be achieved by Xarelto 10 mg, 15 mg, or 20 mg tablets

Approval duration

1 year