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Xarelto — 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 has tried warfarin, fondaparinux injection, or a low molecular weight heparin (LMWH) product (e.g., enoxaparin injection, Fragmin [dalteparin injection]) OR
  • Patient has tried another direct oral anticoagulant (e.g., Pradaxa, Savaysa) OR
  • Patient has been started on Xarelto for the treatment of an acute thromboembolic condition

Reauthorization criteria

  • Response to therapy is required for continuation unless otherwise noted

Approval duration

6 months