Diagnosis: Cardiac/Circulatory Problems.
Treatment: Pharmacy/Prescription Drugs.

The insurer denied Eliquis.
The denial is overturned.

The patient is a female with a history of submassive pulmonary embolism. After receiving second dose of Moderna coronavirus (COVID) vaccine, she presented with shortness of breath. She was diagnosed with bilateral pulmonary embolism. She was started on Enoxaparin therapy which was switched to Eliquis (apixaban) 5 milligrams (mg) twice daily. Her treatment was changed to rivaroxaban (Xarelto) due to denial of coverage of apixaban. She experienced fatigue and dizziness after starting rivaroxaban. She switched her therapy to apixaban. The treating physician is requesting Eliquis (apixaban) which the patient has used in the past without any significant side effects. Apixaban is non formulary.

At issue is whether the formulary drug (warfarin, Xarelto) will be or has been ineffective, would not be as effective as the non-formulary drug (Eliquis) or would have adverse effects.

The health plan's determination is overturned in whole.

The formulary drug (warfarin, Xarelto) has been ineffective and would not be as effective as the non-formulary drug (Eliquis) and would have adverse effects.
The patient has already tried the formulary drug (Xarelto) and has experienced side effects of dizziness and fatigue. Therefore, the formulary option has already been proven to not be clinically helpful but rather harmful to the patient. Therefore, the treating provider is requesting the non-formulary option of apixaban. In addition to the issue of intolerance in this particular patient, the peer reviewed publications have reported apixaban to be more effective than rivaroxaban in preventing the development of recurrent venous thromboembolism and major bleeding events.

Therefore, the formulary drugs would not be as effective as the non-formulary drug.