Limited Coverage Drugs - Ticagrelor

Generic Name: ticagrelor

Strength: 90mg

Form: tablet

Special Authority Criteria

Approval Period

To be taken in combination with ASA 75 mg – 150 mg1 daily for patients with acute coronary syndrome (i.e., ST elevation myocardial infarction [STEMI], non-ST elevation myocardial infarction [NSTEMI] or unstable angina [UA]) with ONE of the following:

Failure on optimal clopidogrel and ASA therapy as defined by definite stent thrombosis2 or recurrent STEMI or NSTEMI or UA after revascularization with Percutaneous Coronary Intervention (PCI)

OR

STEMI, NSTEMI or UA and undergoing revascularization via PCI.

Notes:

  1. Co-administration of ticagrelor with high maintenance dose ASA (> 150 mg daily) is not recommended.
  2. Definite stent thrombosis, according to the Academic Research Consortium, is defined as:
    • a total occlusion originating in or within 5 mm of the stent, or
    • a visible thrombus within the stent, or
    • is within 5 mm of the stent in the presence of an acute ischemic clinical syndrome within 48 hours.

Definite stent thrombosis must be confirmed by angiography or by pathologic evidence of acute thrombosis.

Up to 12 months

Practitioner Exemptions

  • A Collaborative Prescribing Agreement (CPA) is available to a limited number of cardiologists and selected internal medicine specialists working in a cardiology capacity. These practitioners are not required to submit a Special Authority request form for coverage.
  • The CPA is intended for prescribers caring for patients immediately before, during and immediately after PCI. To ensure uninterrupted coverage for patients, prescribers who sign a CPA must write prescriptions for ticagrelor for the full intended duration of therapy (i.e., up to 12 months).
  • Important: PharmaCare coverage covers ticagrelor for patients who meet the Limited Coverage criteria and whose prescription has been written by the cardiologist or selected internal medicine specialist who has entered into a CPA.
  • PharmaCare coverage and actual reimbursement is subject to the rules of a patient’s PharmaCare plan rules, including any annual deductible requirement and any other applicable PharmaCare pricing policy.
  • Each CPA must be signed by the cardiologist or selected internal medicine specialist working in a cardiology capacity who is requesting coverage and not a delegate.
  • Practitioners who have not signed a CPA may submit a Special Authority request if the patient meets the criteria above. These prescriptions will not be covered automatically.

Special Notes

  • Ticagrelor is contraindicated in patients with active pathological bleeding as well as in those with a history of intracranial hemorrhage and moderate to severe hepatic impairment.

Special Authority Request Form