Diagnosis: Blood Disorder.
Treatment: Pharmacy/Prescription Drugs.
The insurer denied Eliquis.
The denial is upheld.

The patient is a male with a past medical history significant for chronic systolic heart rate due to non-ischemic cardiomyopathy (premature ventricular contraction [PVC] mediated), chronic right lower lobe pulmonary embolus, obstructive sleep apnea, chronic kidney disease, paroxysmal atrial fibrillation anticoagulated with apixaban for stroke prevention. The patient's health plan has denied coverage for apixaban (Eliquis) as prescription benefit exception on the grounds that documentation provided does not meet established criteria for prescription benefit exception stating there are alternative formulary anticoagulants, warfarin and Xarelto, that would be appropriate for this patient. The patient's treating cardiologist is requesting an appeal of the patient's health plan denial of prescription benefit plan exception for apixaban for the ongoing treatment of atrial fibrillation and pulmonary embolus.

The health plan's determination is upheld.

There is no clear documentation provided for review of this case that indicates that all of the formulary anticoagulants would be contraindicated or be less effective than apixaban for the treatment of atrial fibrillation and pulmonary embolism in this case. Current published medical literature and expert consensus guideline statements on venous thromboembolism (VTE) and the management of stroke prevention in atrial fibrillation as demonstrated that both warfarin and Xarelto would be medically appropriate anticoagulants in his case. Furthermore, clinical trial data has demonstrated Xarelto to be non-inferior to warfarin for prevention of stroke with an associated lower risk of major bleeding events in patients with atrial fibrillation making this medication preferable over warfarin as an appropriate formulary alternative for this patient (1-3).

Given that documentation provided for review of this case does not demonstrate patient intolerance, treatment failure, or contraindication of any of the alternative formulary anticoagulants, the health plan's determination is upheld in this case.