Limited Coverage Drugs - Rivaroxaban for prophylaxis of venous thromboembolism (VTE)

Generic Name

rivaroxaban for prophylaxis of venous thromboembolism (VTE)

Strength

10 mg
Form tablet
Special Authority Criteria Approval Period
For prophylaxis of VTE following elective total hip replacement surgery or elective total knee replacement surgery.3,4 Following elective total hip replacement: Up to a maximum of 35 days1,2

Following elective total knee replacement: Up to a maximum of 14 days1,2

Practitioner Exemptions

  • A Collaborative Prescribing Agreement (PDF) is available to a limited number of practitioners in the following specialty: orthopaedic surgery.
  • PharmaCare coverage is subject to the patient's PharmaCare plan rules, including any annual deductible requirement.

Special Notes

  1. The duration of therapy includes the period during which doses are administered post-operatively in an acute care (hospital) setting. The PharmaCare approval period is for the balance of the total duration after discharge.
  2. The first dose is typically administered 6 to 8 hours after surgery, assuming adequate hemostasis has been achieved.
  3. The RECORD clinical trial program did not evaluate the efficacy or safety of sequential use of a low molecular weight heparin followed by rivaroxaban for prophylaxis of VTE. Due to the current lack of evidence for sequential use, PharmaCare coverage is not intended for this practice.
  4. Clinical judgment is warranted to assess the increased risk for VTE and/or adverse effects in patients with a history of previous VTE, myocardial infarction, transient ischemic attack or ischemic stroke; a history of intraocular or intracerebral bleeding; a history of gastrointestinal disease with gastrointestinal bleeding; moderate or severe renal insufficiency; severe liver disease; concurrent use of other anticoagulants; or age greater than 75 years.

Special Authority Request Form

Important note regarding hip and knee replacement surgeries: Special Authority request forms are not required and will not be accepted if submitted. PharmaCare coverage of rivaroxaban for the prophylaxis of VTE is only available with a valid Collaborative Prescribing Agreement (PDF).