U.S. Doctors Resources, L.L.C.
PRIOR AUTHORIZATION
DRUG THERAPY:
Xarelto® (rivaroxaban)
| Eliquis® (apaxiban) |
Brilinta® (ticagrelor) |
| Pradaxa® (abifatran) |
Savaysa® (exodaban) |
Disease
MEDICAL REVIEW and DECISION:
The Prior Authorization for this medication has been denied. Further review is pending as:
Clopidogrel 75mg is Free of Deductible in the Exchange.
1. For prevention of blood clotting when no demonstrable deep vein thrombosis has occurred, similar results are noted with salicylates (e.g., ASA 81 mg and dipyridamole 75 mg daily)[1], and/ or warfarin/ coumadin.
[2].
Non-compliant patients or those unable to continue warfarin started Plavix / clopigodrel[2] as
When all risks are considered, clopigrodrel is equivalent with the newer non-vitamin K meds.[3]
2. Contact Benefit Manager for Referral for:
_____a. Alternative Pricing
_____b. Anabolic Protocol for adult sufferers since stanozolol and metformin can reduce Platelet Aggregation Inhibition-1[4].
Pending (1.), (2.) and (3.) the employee/ dependent may continue the medication as prescribed by the treating physician by attaching a valid 3-month prescription with up to 12-months of refills to the Cover Page and mailing it back to:
ATTN: Benefit Manager
City of Hazel Park Self-Insurance Health Program
111 East Nine Mile Road
Hazel Park, Michigan 48030
Please send the demographics about the patient that appear on the Cover Page of the Prior Authorization form and the Credit Card Information from the Flexible Spending Account in the boxes below.
IDENTIFICATION:
| Demographics |
|
Health Insurance/ Credit Card | |
Member Name: | ____________________________________ | Member Name on the Card: | _____________________________________ |
Insurance ID: | ____________________________________ | Issuing Service: | VISA, MC, Discover _________________ |
Date of Birth: | ____________________________________ | Number: | ____________________________________
|
Street Address: | ____________________________________ | Expiration: | ____________________________________
|
City/ State/ Zip code: | ____________________________________ | CVV Code: | ____________________________________ |
Telephone Number: | ____________________________________ |
References:
1. http://www.ncbi.nlm.nih.gov/pubmed/26721914: Circ Heart Fail. 2016 Jan;9(1):e002296. doi: 10.1161/CIRCHEARTFAILURE.115.002296.
Antiplatelet Therapy and Adverse Hematologic Events During Heart Mate II Support.Saeed O1, Shah A1, Kargoli F1, Madan S1, Levin AP1, Patel SR1, Jermyn R1, Guerrero C1, Nguyen J1, Sims DB1, Shin J1, D'Alessandro D1, Goldstein DJ1, Jorde UP
2. http://www.ncbi.nlm.nih.gov/pubmed/26656021: BMJ Open. 2015 Dec 9;5(12):e009267. doi: 10.1136/bmjopen-2015-009267.
Primary Care Atrial Fibrillation Service: outcomes from consultant-led anticoagulation assessment clinics in the primary care setting in the UK.
Das M1, Panter L2, Wynn GJ1, Taylor RM2, Connor N2, Mills JD3, Kirchhof P4, Gupta D1.
3. http://www.ncbi.nlm.nih.gov/pubmed/24204920: PLoS One. 2013 Oct 25;8(10):e77694. doi: 10.1371/journal.pone.0077694. eCollection 2013. New oral anticoagulants are not superior to warfarin in secondary prevention of stroke or transient ischemic attacks, but lower the risk of intracranial bleeding: insights from a meta-analysis and indirect treatment comparisons.
Sardar P1, Chatterjee S, Wu WC, Lichstein E, Ghosh J, Aikat S, Mukherjee D.
4. http://www.ncbi.nlm.nih.gov/pubmed/3113299: Ann Biol Clin (Paris). 1987;45(2):202-6.[Anti-activator inhibitors of plasminogen].[Article in French] Juhan-Vague I, Alessi MC, Aillaud MF.
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Signed b.n.r. Benefit Manager ___________________________________ date:__________
