Diagnosis: Chronic Atrial Fibrillation.
Treatment: Formulary exception for Eliquis.

The insurer denied the Formulary exception for Eliquis.
The denial is overturned.

The patient is a male with chronic atrial fibrillation who has been stable on Eliquis anticoagulation for several years. The patient's provider have requested approval for continued Eliquis treatment.

The health plan denied coverage for Eliquis, since the patient has not tried and had an inadequate treatment response or intolerance to the formulary anticoagulant alternatives (warfarin, Xarelto), or have a documented clinical reason such as expected adverse reaction or contraindication that prevents the patient from trying the formulary alternatives.

Yes, the health plan should cover the Formulary exception for Eliquis.

The formulary anticoagulant drug options under the health plan included warfarin and Xarelto. Warfarin has been well-demonstrated to be inferior to Xarelto and Eliquis for stroke prevention in atrial fibrillation.

Ray et. al published evidence in JAMA (Journal of the American Medical Association) journal revealed that treatment with rivaroxaban compared with apixaban was associated with a significantly increased risk of major ischemic or hemorrhagic events.

Fralick et. al published evidence that showed that adults with atrial fibrillation prescribed apixaban had a lower rate of both ischemic stroke or systemic embolism and bleeding compared with those prescribed rivaroxaban.

Switch from Eliquis to the health plan's formulary alternatives could jeopardize the patient's clinical stability. It is standard of care in clinical practice to continue use of Eliquis in this patient.