skip to content
Primary navigation

Xarelto

DrugXarelto (rivaroxaban) [Janssen] 

August 2016

Therapeutic area - Anticoagulants

Approval criteria

  • Patient has diagnosis of nonvalvular atrial fibrillation AND
  • Prior stroke (ischemic or unknown), transient ischemic attack (TIA) or non-CNS system embolism OR
  • 2 or more of the following risk factors; hypertension, heart failure or left ventricular ejection fraction ≤40%, diabetes mellitus AND
  • Patient has a documented clinical intolerance/contraindication to warfarin OR
  • Patient has tried, at least, a 2-month trial of warfarin and, despite standard of care, was not well controlled OR
  • Patient has had knee or hip replacement surgery AND
  • Treatment will be limited to 12 days with knee replacement surgery OR
  • Treatment will be limited to 35 days with hip replacement surgery OR
  • Patient has a diagnosis of deep vein thrombosis (DVT) OR pulmonary embolism (PE)
  • Patient has a documented clinical intolerance/contraindication to warfarin OR
  • Patient has tried, at least, a 2-month trial of warfarin and, despite standard of care, was not well controlled

Quantity limits

  • Quantity Limit = 34 tablets. If approved for DVT or PE, Xarelto 15 mg will be given a one-time approval for a quantity of 42 (Initial dosing in DVT is Xarelto 15 mg twice daily for 21 days, then Xarelto 20 mg once daily.)

Questions?

MHCP Provider Call Center 651-431-2700 or 800-366-5411

back to top