Limited Coverage Drugs - Rivaroxaban 10mg

Generic Name / Strength / Form
rivaroxaban 10mg

Criteria Approval Period

Prophylaxis of venous thromboembolism following elective total hip replacement surgery or elective total knee replacement surgery, where the initial post-operative doses are administered in an acute care (hospital) setting. See Special Notes below.

Up to a 35-day total following elective total hip replacement

Up to a 14- day total following elective total knee replacement

Practitioner Exemptions

  • PharmaCare coverage will only be provided for a patient who meets the Limited Coverage criteria, and whose prescription written by an orthopedic surgeon who has entered into a Collaborative Prescribing Agreement. See Collaborative Prescribing Agreement (PDF 138K).
  • Due to the individual nature of each Collaborative Prescribing Agreement, the Agreement must be signed by the orthopedic surgeon and not his/her delegates.

Special Notes

  1. The total duration of therapy includes the period during which doses are administered post-operatively in an acute care (hospital) setting, and the approval period is for the balance of the total duration after discharge.
  2. The first dose is typically administered 6 to 8 hours after surgery, assuming adequate hemostasis has been achieved.
  3. The RECORD clinical trial program did not evaluate the efficacy or safety of sequential use of a low molecular weight heparin followed by rivaroxaban. Due to the current lack of evidence for sequential use, PharmaCare coverage is not intended for this practice.
  4. Clinical judgment is warranted to assess the increased risk for venous thromboembolism and/or adverse effects in patients with a history of previous venous thromboembolism, myocardial infarction, transient ischemic attack or ischemic stroke; a history of intraocular or intracerebral bleeding; a history of gastrointestinal disease with gastrointestinal bleeding; moderate or severe renal insufficiency; severe liver disease; concurrent use of other anticoagulants; or age greater than 75 years.

Special Authority Request Form

Important Note: Special Authority request forms are not required and, in fact, will not be accepted if submitted. PharmaCare coverage for rivaroxaban is only available with a valid Collaborative Prescribing Agreement (PDF 138K).