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The Policy VaultThe Policy Vault

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

Treatment or Prevention of Other Thromboembolic-Related Conditions (e.g., superficial vein thrombosis, splanchnic vein thrombosis, hepatic vein thrombosis, or prophylaxis of venous thromboembolism in a high-risk patient)

Initial criteria

  • Patient has tried warfarin, fondaparinux, or a low molecular weight heparin product (e.g., enoxaparin, Fragmin [dalteparin injection]) OR patient has tried Eliquis (apixaban tablets or tablets for oral suspension), Eliquis Sprinkle (apixaban capsules for oral suspension), Pradaxa (dabigatran capsules and oral pellets), or Savaysa (edoxaban tablets)

Approval duration

6 months