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Title: |
Lovenox®, Arixtra® Prior Authorization
Lovenox Quantity Limit Override Criteria |
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Program Objectives: |
| The intent of the Lovenox® and Arixtra® prior authorization program is to promote appropriate utilization according to the FDA-approved indications and/or clinical studies and/or practice guidelines. In addition, the Lovenox quantity limit encourages appropriate dosing according to the FDA-approved labeling; the quantity limit is 12 syringes per month. |
Effective Date: |
| 03/08 for Oklahoma |
Prior Authorization Criteria For Approval: |
Lovenox®, Arixtra® - Prior Authorization program
Initial and Renewal Evaluation
1. Does the patient have a diagnosis included in the FDA-labeled indications for these medications? [see table below]
If yes, approve for 6 months. If no, continue to 2.
2. Has the prescriber submitted documentation in support of the requested therapeutic use for the requested medication?
If yes, pharmacist must review and may approve for 6 months based on information provided.
If no, deny.
[For Lovenox subject to quantity limit, please see criteria below.]
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Lovenox® - Quantity Limit Override criteria
Initial and Renewal Evaluation
1. Is the quantity requested greater than the set limit of 12 syringes per month?
If yes, continue to 2.
If no, review is not applicable. Claim will adjudicate.
2. Has the prescriber submitted documentation in support of one of the following:
a. Patient requires extended treatment or primary or secondary prophylaxis of thromboembolism during pregnancy
b. Patient has cancer and requires extended prophylaxis and/or treatment of symptomatic VTE (proximal DVT and/or PE), to reduce the recurrence of VTE
If yes, approve for 6 months.
If no, continue to 3.
3. Has the prescriber submitted documentation in support of the requested therapeutic use and quantity for the requested medication?
If yes, pharmacist must review and may approve for 6 months based on information provided.
If no, deny.
Table - FDA-Approved Indications
| Indication |
Fragmin (Dalteparin) |
Lovenox (Enoxaparin) |
Arixtra (Fondaparinux) |
Innohep (Tinzaparin) |
| Treatment of acute symptomatic DVTa ± PE (given in conjunction with warfarin) |
|
x |
x |
x |
| Outpatient treatment of DVT without PE (given in conjunction with warfarin) |
|
x |
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Prophylaxis of DVT, which may lead to PE:
-Patients undergoing abdominal surgery who are at risk of thromboembolic complications |
x |
x |
x |
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| -Patients undergoing hip fracture surgery |
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|
x |
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| -Patients undergoing hip replacement |
x |
x |
x |
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| -Patients undergoing knee replacement |
|
x |
x |
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| -Patients at risk of thromboembolism due to severely restricted mobility during acute illness |
x |
x |
|
|
| Prophylaxis of ischemic complications of unstable angina and non-Q-wave MI (concurrently administered with aspirin) |
x |
x |
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| Treatment of acute ST-segment elevation MI (STEMI) |
|
x |
|
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| Extended treatment of symptomatic VTE (proximal DVT and/or PE), to reduce the recurrence of VTE in patients with cancer |
x |
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| a. DVT = deep vein thrombosis; PE = pulmonary embolism; VTE = venous thromboembolism; MI = myocardial infarction |
| CPT® only copyright 2003 American Medical Association. All Rights Reserved. | |
