Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form

nadroparin

Criteria

Approval Period (to complete the balance of a total duration of therapy for outpatients)

TREATMENT OF VENOUS THROMBOEMBOLISM
1. Treatment of acute deep vein thrombosis or pulmonary embolus continued from an acute care (hospital) setting to bridge time to achieve therapeutic INR on oral anticoagulants. 1. Up to 10 days supply
OR
2. Following failure on oral anticoagulant therapy (recurrence of one or more deep vein thromboses or pulmonary emboli in patients with therapeutic INR on oral anticoagulants). 2. Up to 3 months, then reassessed
OR
PROPHYLAXIS OF VENOUS THROMBOEMBOLISM
3. Following elective total knee replacement surgery. 3. Up to 14 days
OR
4. Following elective total hip replacement surgery. 4. Up to 35 days
OR
5. Following orthopedic surgery for major trauma. 5. Up to 10 days
OR
6. Concurrent lupus anticoagulant syndrome, antiphospholipid syndrome, or thrombophilia. 6. Up to 3 months
OR
7. Associated with pregnancy. 7. Up to 4 weeks post-partum.

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • The total duration of therapy includes the period during which doses are administered post-operatively in an acute care (hospital) setting, and the approval period is for the balance of the total duration after discharge (i.e., for outpatients only).

Special Authority Request Form(s)

Click on the Special Authority request form link below.

Low Molecular Weight Heparin Form (PDF, 133KB)