Limited Coverage Drugs - Nadroparin

Generic Name / Strength / Form
Fraxiparine / 2,850 Iu(Anti-Xa)/0.3 mL / SYRINGE
Fraxiparine / 3,800 Iu(Anti-Xa)/0.4 mL / SYRINGE
Fraxiparine / 5,700 Iu(Anti-Xa)/0.6 mL / SYRINGE
Fraxiparine / 9,500 Iu(Anti-Xa)/0.3 mL / SYRINGE
Fraxiparine / 11,400 Iu(Anti-Xa)/0.6 mL / SYRINGE
Fraxiparine / 15,200 Iu(Anti-Xa)/0.8 mL / SYRINGE
Fraxiparine / 19,000 Iu(Anti-Xa)/1 mL / SYRINGE

 

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

  • PharmaCare coverage will be provided for a patient who meets the Limited Coverage criteria, and whose prescription is written by an orthopedic surgeon who has entered into a Collaborative Prescribing Agreement.

  • Due to the individual nature of each Collaborative Prescribing Agreement, the Agreement must be signed by the prescriber and not his/her delegate.

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)