Limited Coverage Drugs - tinzaparin

Generic Name / Strength / Form

Tinzaparin / 2,500 IU (Anti-Xa)/0.25 mL / SYRINGE
Tinzaparin / 3,500 IU (Anti-Xa)/0.35 mL / SYRINGE
Tinzaparin / 4,500 IU (Anti-Xa)/0.45 mL / SYRINGE
Tinzaparin / 8,000 IU (Anti-Xa)/0.4 mL / SYRINGE
Tinzaparin / 10,000 IU (Anti-Xa)/0.5 mL / SYRINGE
Tinzaparin / 12,000 IU (Anti-Xa)/0.6 mL / SYRINGE
Tinzaparin / 14,000 IU (Anti-Xa)/0.7 mL / SYRINGE
Tinzaparin / 16,000 IU (Anti-Xa)/0.8 mL / SYRINGE
Tinzaparin / 18,000 IU (Anti-Xa)/0.9 mL / SYRINGE
Tinzaparin / 10,000 IU (Anti-Xa)/mL / 2 mL/ VIAL
Tinzaparin / 20,000 IU (Anti-Xa)/mL/ 2 mL/ VIAL

Special Authority Criteria

Approval Period

Treatment of venous thromboembolism

For the treatment of:

patients with acute deep vein thrombosis or pulmonary embolus who continue to receive care after leaving an acute care (hospital) setting. This treatment bridges the time gap to achieve therapeutic INR on oral anticoagulants

OR

patients with treatment failure on oral anticoagulant therapy (recurrence of one or more deep vein thromboses or pulmonary emboli in patients with therapeutic INR on oral anticoagulants)

OR

patients, associated with cancer, who have failed, or who are unable to tolerate, oral therapy with warfarin

Up to 10 days’ supply

 

 

Up to 3 months, then
reassessed

 

 

Up to 6 months

Prophylaxis of venous thromboembolism

For prevention in patients:

following elective total knee replacement surgery

OR

following elective total hip replacement surgery

OR

following orthopedic surgery for major trauma

OR

with lupus anticoagulant syndrome, antiphospholipid syndrome, or thrombophilia

OR

before, during or after pregnancy

 

Up to 14 days

 

Up to 35 days

 

Up to 10 days

 

Up to 3 months

 

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)