Diagnosis: Pulmonary Embolism (PE)

Treatment: Eliquis

The insurer denied coverage for Eliquis

The denial is overturned.

The patient has a history of hereditary hemochromatosis, hyperlipidemia, acute Pulmonary Embolism. The patient has been treated with Eliquis for his pulmonary embolism (PE). He had been stable on Eliquis (a direct oral anticoagulants [DOAC]) for 2 years. The patient was switched to Xarelto due to change in his insurance formulary. He developed a severe allergic reaction to Xarelto with hives. The patient required to be treated with Benadryl and Medrol Pack for treatment of same.

This patient has a contraindication to Xarelto due to severe allergic reaction. The 2 drugs in the approved formulary are Xarelto and Warfarin. There is no other substitute other than Xarelto in the same class (DOAC). Warfarin is in a different class and not suitable for the patient due to need for frequent blood draws and drug interactions.

Based on review of records and above Eliquis should be reinstituted. DOAC would be preferred over Warfarin in this patient due to less side effects such as bleeding, better tolerability and less drug-to-drug interaction and no requirement of frequent blood testing.

The preferred drug is likely to be more effective that the formulary drugs.

The insurer's denial of coverage for Formulary Exception for Eliquis is overturned.