Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Deep vein thrombosis (DVT)

Treatment: Eliquis (apixaban)	

The insurer denied coverage for Eliquis (apixaban).
 
The denial is upheld.

This is a patient with a history of ulcerative colitis and deep vein thrombosis (DVT). The continuation of treatment with Eliquis (apixaban) is requested.

The patient presented to the emergency department (ED) for complaints of abdominal pain with progressive daily bloody diarrhea the week before. She had a computed tomography (CT) which revealed a non-occlusive thrombus within the left common iliac vein extending into the left external iliac vein and left internal iliac vein and its tributaries. It also showed a non-occlusive thrombus within the right internal iliac vein. The patient reported having abdominal pain at injection sites with Lovenox.

The alternatives are not likely to cause a reaction. The appeal argues that apixaban is safer and associated with a low risk of bleeding. However, any of the types of anticoagulation therapies are similar. Studies show that low-dose molecular heparin is efficacious in IBD [irritable bowel disease]. 

The formulary drugs have not been shown to be ineffective based on the patient's clinical history. She has been using Lovenox and reported having pain at injection sites which is a common occurrence and diminishes.

"Bleeding complications are an important consideration when choosing any systemic anticoagulation. Major bleeding, such as central nervous system bleeding and cardiac tamponade, can be a dreaded complication with any factor Xa (xaban) inhibitors. Although a reversal agent, andexanet, has been recently approved for apixaban and rivaroxaban, it has several limitations in terms of short half-life, potential increased risk of thrombosis, absence of RCTs [randomized controlled trials] on its efficacy, and cost. Hence, complications are often managed conservatively. Our study provides further evidence that apixaban might be a better choice for anticoagulation than rivaroxaban in terms of bleeding risk pending the ongoing RCT previously mentioned. At the very least, our results would appear to favor the use of apixaban in patients with a preexisting increased risk to bleed, for example, those with CKD [chronic kidney disease], heavy menses, or history of gastrointestinal bleed. In these circumstances, our findings suggest that patients who are taking long-term rivaroxaban will likely benefit if switched to apixaban if they are able to adhere to twice-daily treatment. However, it should be noted that our findings are applicable to VTE [venous thromboembolism] patients [not AF (atrial fibrillation)] only, and whether this study's findings would continue to hold true beyond 6 months follow-up is unclear. Although decreased bleeding with apixaban exists, it may be small as evidenced by number needed to harm, which can be useful information while discussing the options of anticoagulation between these agents with our patients." (Aryal, et al, 2019)     

Eliquis would not be more effective than the formulary drug. Eliquis and Xarelto are comparable.

The insurer's denial of coverage for formulary exception for Eliquis (apixaban) is upheld.