| Criteria |
Approval Period |
| 1. Treatment of acute deep vein thrombosis or pulmonary emboli. | 1. Up to ten days supply |
OR |
2. Failure on oral anticoagulant treatment (reoccurrence of one or more deep vein thrombosis or pulmonary emboli) or failure to reach therapeutic INR while on oral anticoagulants. |
2. Up to three months |
OR |
3. Prophylaxis of lupus anticoagulant syndrome, antiphospholipid syndrome or thrombophilia. |
3. Up to three months |
OR |
4. Prophylaxis post-operative after total knee arthroplasty or major orthopedic trauma. |
4. Up to ten days |
OR |
5. Pregnancy. |
5. Up to four weeks post-partum. |
