Recommended authorization criteria for Eliquis (apixaban) products
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Recommended authorization criteria for pharmacy benefit coverage of Eliquis (apixaban) products, including tablets, tablets for oral suspension, and Eliquis Sprinkle; applies to requests for coverage and prior authorization determinations by Medical Mutual - Ohio.
No material clinical or coverage changes in this revision.
Recommended Authorization Criteria
Recommended authorization criteria by indication
Coverage is recommended for Eliquis products when the indication-specific criteria (age/weight and prior-therapy requirements) below are met. Approval durations are shown per indication.
ALL of the following
- Treatment or Prevention of Other Thromboembolic-Related Conditions (patients ≥ 35 kg): Approve for 6 months if criteria A and B are met.
- A: Patient is ≥ 35 kg.
B - ONE of
- Patient has tried warfarin, fondaparinux injection, or a low molecular weight heparin (LMWH) product (e.g., enoxaparin, dalteparin).
- Patient has been started on Eliquis tablets for the treatment of an acute thromboembolic condition.
Exception: A patient who has tried rivaroxaban (Xarelto), dabigatran (Pradaxa), or edoxaban (Savaysa) is not required to trial warfarin, fondaparinux, or LMWH before approval.
ALL of the following
- Venous thromboembolic events — Treatment (patients < 35 kg) using Eliquis tablets for oral suspension or Eliquis Sprinkle: Approve for 1 year if patient weighs < 35 kg.
- Venous thromboembolic events — To Reduce the Risk of Recurrence (patients < 35 kg) using Eliquis tablets for oral suspension or Eliquis Sprinkle: Approve for 1 year if patient weighs < 35 kg.
Automation and Coding Rules
| I48.* | Atrial fibrillation and flutter (used for automation) |
| I82* | Other venous embolism and thrombosis (used for automation) |
| I27.82 | Chronic pulmonary embolism (used for automation) |
| Z96.6* | Presence of cardiac valve prosthesis (used for automation) |
Prior Authorization and Documentation
Prior authorization required; automation uses specified ICD-10 and age/claim rules
Prior authorization is recommended for pharmacy benefit coverage of Eliquis; approvals are provided when the conditions in the criteria and initial/extended approval are met. When available, automation uses the listed ICD-10 codes and age/claim-history rules to allow approval of Eliquis tablets.
- Automation example codes for approval: I48.*; I82*; I27.82 with patient 18 years or older
- Automation alternative: Z96.6* with patient 18 years or older and no 2 claims for the same medication within the last 180 days
Provide documentation upon request or risk denial of reimbursement
The Company reserves the right to request additional documentation as part of its coverage determination process and may deny reimbursement if the drug or services were not medically necessary, investigational/experimental, not within scope of benefits, or if a pattern of inappropriate or excessive billing/practice is found.
- Providers must make available upon request patient records, test results, and/or credentials of the provider ordering or performing a service to support medical necessity
- The Company may modify, revise, change, apply and interpret this policy at its sole discretion
Product Formulations and Age/Weight Bands
Initial Approval Criteria by Indication
Initial approval
Initial approvals are granted per indication when the criteria below are met. Durations shown reflect the initial approval period.
Continuation and Extended Approval
Continuation therapy
Reauthorization requires documented response to therapy unless otherwise noted; indication-specific durations apply.
Step Therapy Requirements
| Step | Requirement | Failure criteria / exceptions | Approval duration |
|---|---|---|---|
| 1 | Required trial of an alternative anticoagulant for certain 'other thromboembolic-related conditions' | Patient has tried warfarin, fondaparinux injection, or a low molecular weight heparin (LMWH) product (e.g., enoxaparin, dalteparin). Note: patients who have tried rivaroxaban (Xarelto), dabigatran (Pradaxa), or edoxaban (Savaysa) are not required to try warfarin/fondaparinux/LMWH. | 6 months |
| 1 | Alternate path — patient already started on Eliquis for an acute thromboembolic condition | If patient has been started on Eliquis for treatment of an acute thromboembolic condition, a prior trial of warfarin/fondaparinux/LMWH is not required. | 6 months |
| 1 | Weight-based distinction — patients ≥35 kg | For other thromboembolic-related conditions in patients ≥35 kg, the same trial requirement applies; patients started on Eliquis for an acute condition are excepted. (See failure criteria/exceptions above.) | 6 months |
| 1 | Other thromboembolic-related conditions in patients <35 kg (use of oral suspension or Sprinkle formulations) | Patient has tried warfarin, fondaparinux, or LMWH OR has been started on Eliquis tablets for oral suspension or Eliquis Sprinkle for an acute thromboembolic condition. | 6 months |
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