Antiplatelet Drugs Prior Authorization (Zontivity / vorapaxar)
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Defines prior authorization (PA) criteria and administrative details for antiplatelet medications for Georgia Medicaid Fee-for-Service members, including covered agents and PA process instructions for prescribers and pharmacies.
No material clinical or coverage changes in this revision.
Coverage Criteria
Zontivity (vorapaxar) Initial Therapy
Zontivity (vorapaxar) is approvable when ALL of the following are met:
Age requirement from PA summary.
Indication specified in PA summary.
Concomitant use requirement from PA summary.
No additional exclusion criteria are listed in this summary. Any exceptions to the stated coverage conditions are evaluated through the prior authorization process; providers should initiate a prior authorization request when seeking coverage for an exception.
Initial Therapy Criteria
Zontivity initial therapy
Initial coverage criteria for Zontivity.
Consolidated initial therapy criteria from PA summary.
Continuation and Authorization Duration
Authorization Duration
Duration of authorization for approved antiplatelet agents.
Applies to PA approvals unless otherwise specified.
Provider Actions and Prior Authorization
Prior authorization required for Zontivity (vorapaxar) in adults
Zontivity (vorapaxar) requires prior authorization for use in members 18 years and older for reduction of thrombotic cardiovascular events in patients with a history of myocardial infarction (MI) or peripheral arterial disease (PAD) when used concomitantly with clopidogrel or aspirin. Providers ordering Zontivity must obtain PA before dispensing; this impacts prescribing and may limit immediate coverage if not secured.
- Applies to members age 18 and older
- Indication: reduction of thrombotic cardiovascular events with prior MI or PAD
- Must be used concomitantly with clopidogrel or aspirin per approval
Refer to Preferred Drug List (PDL) for preferred agents
Consult the Georgia Preferred Drug List (PDL) to determine preferred versus non‑preferred antiplatelet agents; PDL status informs which agents are preferred and may influence coverage edits or PA requirements.
- Online PDL access: http://dch.georgia.gov/preferred-drug-lists
- PDL status may affect prior authorization or step edits for agents listed
Initiate PA via OptumRx and follow the PA Request Process Guide
Initiate prior authorization requests through OptumRx as outlined in the PA Request Process Guide; follow the online PA process instructions and submit required documentation per the guide.
- OptumRx phone for PA initiation: 1-866-525-5827
- PA Request Process Guide available at: http://dch.georgia.gov/prior-authorization-process-and-criteria (click Prior Authorization (PA) Request Process Guide)
Coverage exceptions and denial risk if PA not obtained
Coverage exceptions are considered only through the prior authorization process; failure to obtain an approved PA may result in non‑coverage or denial of the request.
- Exceptions to coverage conditions are handled via PA
- If PA is not obtained, coverage may be denied
Covered Drugs and Codes
| Aspirin | Aspirin generic (OTC) |
| Aspirin/dipyridamole | Aspirin/dipyridamole generic |
| Brilinta | Brilinta (ticagrelor) |
| Cilostazol | Cilostazol generic |
| Clopidogrel | Clopidogrel generic |
| Dipyridamole | Dipyridamole generic |
| Prasugrel | Prasugrel generic |
| Zontivity | Zontivity (vorapaxar) |
Step Therapy and Preferred Agents
| Step | Requirement / Note |
|---|---|
| 1 | Consult the Preferred Drug List (PDL) for preferred antiplatelet agents; PDL status may influence step edits or the need for prior authorization. For online access to the PDL, see http://dch.georgia.gov/preferred-drug-lists. |
Quantity Limits
Background
Antiplatelet agents are used to reduce thrombotic cardiovascular events in patients with conditions such as myocardial infarction (MI) and peripheral arterial disease (PAD). These agents—including aspirin, clopidogrel and others—are prescribed to lower the risk of recurrent ischemic events and vascular complications in patients at elevated thrombotic risk.
Vorapaxar (Zontivity) is a protease-activated receptor-1 antagonist specifically indicated to reduce thrombotic cardiovascular events in patients with a history of MI or PAD when used in combination with aspirin or clopidogrel; use of Zontivity requires prior authorization per the PA criteria.
Definitions
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