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Eliquis — Medical Mutual

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

Initial criteria

  • Patient is age ≥ 18 years
  • Patient meets ONE of the following: i. The patient has tried warfarin, fondaparinux injection, or a low molecular weight heparin (LMWH) product (e.g., enoxaparin injection, Fragmin [dalteparin injection]); OR ii. The patient has been started on Eliquis for the treatment of an acute thromboembolic condition

Reauthorization criteria

  • Response to therapy required for continuation

Approval duration

6 months