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Limited Coverage Drugs - Special Authority Criteria
| Generic Name / Strength / Form |
| dalteparin |
| 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. |
Practitioner Exemptions
- No practitioner exemptions
Special Notes
Low Molecular Weight Heparin Form (PDF)
Click on the link to complete the special authority request form.
PDF Format
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Last Revised: June 21, 2006
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