Cardiac/ Circulatory Problems
Pharmacy/ Prescription Drugs
Health Plan:
CVS Caremark
Upheld upheld
Appeal Type:
Formulary Exception
Age Range:
Decision Year:
Appeal Agent:
Kepro dba IMEDECS
Case Number:

Diagnosis: Cardiac/Circulatory Problems. Treatment: Pharmacy/Prescription Drugs. The insurer denied Eliquis (apixaban). The denial is upheld. This patient is a male with a history of persistent atrial fibrillation with prior ablations currently being treated with apixaban (Eliquis) for prevention of stroke. According to the patient's provider, he has not been treated with other anticoagulants. The patient's health plan has denied prescription benefit exception request for apixaban on the grounds the patient has not met prescription benefit exception criteria including treatment failure, intolerance or adverse effects to the other formulary anticoagulants, warfarin and Xarelto. The patient's provider is appealing this denial. At issue is whether the formulary drugs, warfarin, Xarelto, will be or have been ineffective, would not be as effective as the non-formulary drug, Eliquis, or would have adverse effects. The health plan's determination is upheld in whole. Based on the patient's records provided for review of this case, there is no documented reason why the patient would have adverse effects to the formulary anticoagulant, Xarelto. Xarelto is an appropriate anticoagulant to prevent stroke in this patient with persistent atrial fibrillation as recommended by the 2019 American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Rhythm Society (HRS) focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. (1) There is no clear documented reason that the patient would have an adverse effect or treatment failure to the formulary anticoagulant Xarelto, that Xarelto would be ineffective, or would not not be as effective as Eliquis.


1)January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC Jr, Ellinor PT, Ezekowitz MD, Field ME, Furie KL, Heidenreich PA, Murray KT, Shea JB, Tracy CM, Yancy CW. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2019;74:104-132.