Limited coverage criteria – nadroparin

 

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Generic name	fraxiparine
Strength	Form

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

Special Authority criteria	Approval period (to complete balance of duration of therapy for outpatients)
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	Up to 10 days supply
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)	Up to 3 months, then reassessed
Following elective total knee replacement surgery	Up to 14 days
Following elective total hip replacement surgery	Up to 35 days
Following orthopedic surgery for major trauma	Up to 10 days
Concurrent lupus anticoagulant syndrome, antiphospholipid syndrome, or thrombophilia	Up to 3 months
Associated with pregnancy	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 (CPA)

• Due to the individual nature of each CPA, the agreement must be signed by the prescriber and not their 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)

• Log in to eForms
• HLTH 5338 – Low Molecular Weight Heparin - Dalteparin / Enoxaparin / Nadropparin / Tinzaparain (PDF, 1.1MB)
• HLTH 5469 – Treatment of Venous Thromboembolism In Cancer Patients (PDF, 1MB)