Currentmedical mutual - ohioPolicy N/A

Xarelto (rivaroxaban)

Pharmacy benefit prior-authorization policy for Xarelto (rivaroxaban) tablets and rivaroxaban oral suspension describing recommended coverage criteria, approval durations, automation ICD-10 logic, documentation rights, and conditions not recommended for approval. Applies to adults and certain pediatric indication (Fontan patients age 2-<18).

Policy Summary

Payermedical mutual - ohio

PolicyXarelto (rivaroxaban)

Policy CodePolicy N/A

Change TypeAnnual review — clarified dates, no material changes

Effective Date

Next Review DateOct 16, 2025

Key ActionPrior authorization is recommended for pharmacy benefit coverage of Xarelto; approval recommended when criteria in this policy are met.

POLICY UPDATE CHANGES

Annual Review Date and Last Revised Date are 10/16/2025 as listed.

8+FDA-approved indication groups listed

2Approval durations commonly 2 years

60 daysShort approval duration for prophylaxis indications

Coverage Summary

Coverage stance: Covered with criteria — Xarelto (rivaroxaban) tablets and rivaroxaban oral suspension are recommended for coverage when the patient and indication meet the policy’s authorization criteria. Scope: pharmacy benefit prior-authorization policy for Xarelto tablets and rivaroxaban oral suspension describing recommended coverage criteria, approval durations, automation ICD-10 logic, documentation rights, and conditions not recommended for approval; applies to adults and a specific pediatric population (Fontan patients age ≥ 2 years and < 18 years). Product summary: Xarelto is an oral factor Xa inhibitor indicated for multiple thromboembolic and cardiovascular indications including nonvalvular atrial fibrillation, DVT/PE treatment and prevention, VTE prophylaxis in surgical and acutely ill patients, PAD/CAD in combination with aspirin, and thromboprophylaxis in pediatric Fontan patients; rivaroxaban oral suspension is available for patients who cannot appropriately receive tablets.

Recommended Authorization Criteria — FDA-Approved Indications (Initial)

Recommended Authorization Criteria — FDA-Approved Indications

Coverage of Xarelto (tablets) and rivaroxaban oral suspension is recommended in those who meet one of the following criteria:

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Automation Criteria for Approval

Billing Rule

Automation logic for approvals

Automation will approve when the policy's listed ICD-10 diagnosis codes, age criteria, and prior-claim conditions are met. Specifically, automation uses the ICD-10 code groups I48.*, I82*, I27.82, and Z96.6* and applies the age requirements and prior-claim lookback described in the policy.

I48.*
I82*
I27.82
Z96.6*
Prior-claim lookback: has not had 2 claims for the same medication within the last 180 days

Other Uses with Supportive Evidence

Treatment or prevention of other thromboembolic-related conditions (examples: superficial vein thrombosis, splanchnic vein thrombosis, hepatic vein thrombosis, prophylaxis in high-risk patients).

ALL of the following

Criterion A
- Patient has tried warfarin, fondaparinux, or a low molecular weight heparin product (e.g., enoxaparin, dalteparin)
- Patient has been started on Xarelto for the treatment of an acute thromboembolic condition
Criterion B (for rivaroxaban oral suspension)
- Patient is unable to have Xarelto tablets appropriately administered
- The prescribed dose cannot be achieved by Xarelto 10 mg, 15 mg, or 20 mg tablets

Other thromboembolic-related conditions with supportive evidence include examples such as superficial vein thrombosis, splanchnic vein thrombosis, hepatic vein thrombosis, and prophylaxis in high-risk patients; these are described as supported-use examples for consideration under the policy.

Conditions Not Recommended for Approval

Coverage is not recommended for circumstances not listed in the Recommended Authorization Criteria.

ANY of the following

Indications/uses not listed in the Recommended Authorization Criteria
Other conditions with limited/preliminary data or potential safety concerns (not an exhaustive list)

Coverage is not recommended for circumstances outside the Recommended Authorization Criteria; this includes indications or uses not listed and other conditions with limited or preliminary data or potential safety concerns. This list is not exhaustive and criteria may be updated as new published data become available.

Provider Actions & Administrative Requirements

Prior Authorization

Prior authorization recommended

Prior authorization is recommended for pharmacy benefit coverage of Xarelto; approval recommended when criteria in this policy are met.

Documentation Required

Documentation may be requested

The company may request patient records, test results, and/or provider credentials to support medical necessity. The Company may deny reimbursement when it determines the drug or services are not medically necessary, investigational/experimental, not within benefits, or when inappropriate/excessive billing or practice is found.

Billing Rule

Automation logic for approvals

When available, automation will approve based on the policy's listed ICD-10 codes, age criteria, and prior-claim conditions. The same ICD-10 codes and the prior-claim lookback threshold apply for automated approvals.

I48.*
I82*
I27.82
Z96.6*
Prior-claim lookback: has not had 2 claims for the same medication within the last 180 days

Approval durations vary by indication: most chronic or long-term indications (e.g., atrial fibrillation, CAD, PAD, DVT/PE treatment and reduction of recurrence, pediatric Fontan thromboprophylaxis) are authorized for 2 years, while prophylaxis indications for perioperative or acutely ill patients (e.g., DVT prophylaxis after knee/hip replacement and VTE prophylaxis in an acutely ill medical patient) are authorized for shorter periods, commonly 60 days; select other thromboembolic uses supported by evidence may be authorized for 6 months.

Background and Clinical Evidence

Xarelto (rivaroxaban) is an oral factor Xa inhibitor anticoagulant with FDA indications that include reduction in the risk of stroke and systemic embolism in nonvalvular atrial fibrillation; prophylaxis of DVT (which may lead to PE) in patients undergoing hip or knee replacement surgery; treatment of DVT and PE and reduction in the risk of recurrent DVT and PE following initial therapy; prophylaxis of venous thromboembolism in acutely ill medical patients; use in combination with aspirin to reduce major CV events in chronic CAD or PAD; and thromboprophylaxis in pediatric patients who have undergone the Fontan procedure. Definition: Rivaroxaban oral suspension — a liquid formulation (brand or generic) used when tablets cannot be appropriately administered or when the required dose cannot be achieved with available tablets.

Primary prescribing information: Xarelto tablets prescribing information; Janssen; January 2022.

Policy Summary

Payermedical mutual - ohio

PolicyXarelto (rivaroxaban)

Policy CodePolicy N/A

Change TypeAnnual review — clarified dates, no material changes

Effective Date

Next Review DateOct 16, 2025

Key ActionPrior authorization is recommended for pharmacy benefit coverage of Xarelto; approval recommended when criteria in this policy are met.

On This Page

OpenPayer

Xarelto (rivaroxaban)

Coverage Summary

Recommended Authorization Criteria — FDA-Approved Indications (Initial)

Automation Criteria for Approval

Other Uses with Supportive Evidence

Conditions Not Recommended for Approval

Provider Actions & Administrative Requirements

Applicable Codes

Background and Clinical Evidence

Revision History

I48.*	Atrial fibrillation and flutter (wildcard as listed)
I82*	Other venous embolism and thrombosis (wildcard as listed)
I27.82	Chronic pulmonary embolism
Z96.6*	Presence of prosthetic heart valve (wildcard as listed)