Cost reduction strategies and common references including authorization details

PULMONARY EMBOLISM

Cost reduction strategies and common references including authorization details

Medicaid Patients

  • Most patients are eligible for 1 month of a free DOAC prescription fill using prescription assistance cards
  • Check state or individual Medicaid formulary, one specific DOAC may be covered while others are not

Commercial Insurance Patients

  • Most patients are eligible for 1 month of a free DOAC prescription fill using prescription assistance cards
  • Encourage use of prescription assistance cards

Medicare

  • Most patients are eligible for 1 month of a free DOAC prescription fill using prescription assistance cards
  • Check formulary to see if specific DOAC is covered preferentially over others
  • For patients with low income, encourage them to apply for “Low-Income Subsidy”

References for Common Prior Authorization Questions

Diagnosis Code

Guideline Recommendation for DOAC as first line therapy:

Use of a direct oral anticoagulant (apixaban, dabigatran, edoxaban or rivaroxaban) is considered first line therapy for treatment of acute PE and deep vein thrombosis and is recommended preferentially over warfarin therapy. (American College of Chest Physicians Guideline, 2016).

Reference: Chest 2016; 149:315-352.

Renal Function and DOACs:

Renal function (serums creatinine and/or creatinine clearance) should be followed regularly to ensure appropriate dosing. We recommend using the Cockcroft Gault Calculator that uses actual body weight to assess renal function. We advise against using the ideal body weight as this can lead to incorrect dosing.

Online calculator for Creatinine Clearance (using age, gender, weight and serum creatinine): http://nephron.com/cgi-bin/CGSI.cgi

ICD-10-CM:

126.99
Acute massive pulmonary embolism (HCC)

126, 92
Acute saddle pulmonary embolism (HCC)

126.02
Acute saddle pulmonary embolism with acute cor pulmonale

126.92
Acute saddle pulmonary embolism without acute cor pulmonale

126.09
Other acute pulmonary embolism with acute cor pulmonale

126.99
Other acute pulmonary embolism without acute cor pulmonale

Anticoagulant Prescription Details
Patient Handout