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Table 58: Anticoagulants and Antiplatelet Agents

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Drug Category: Blood and Circulation

Medication Class/Individual Agents: Anticoagulants and Antiplatelet Agents

I. Prior-Authorization Requirements

 Antiplatelet Agents

Clinical Notes
Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes
anagrelide Agrylin test   #
aspirin / extended-release dipyridamole Aggrenox test   #
cilostazol test  
clopidogrel Plavix test   #
dipyridamole test  
prasugrel Effient test   #
ticagrelor Brilinta test  
vorapaxar Zontivity PA  

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

  

Antiplatelet Agents:

  • Antiplatelet agents play a major role in the management of cardiovascular (CV), cerebrovascular, and peripheral vascular diseases. The recommendation for use of these agents as monotherapy or combination therapy depends on the specific clinical indication and the patient’s risk for thromboembolic events and/or bleeding events.
  • Prasugrel has a more rapid onset of action, is more potent than clopidogrel, and produces more consistent platelet inhibition. Ticagrelor belongs to a newer class called cyclopentyltriazolopyrimidines. Unlike clopidogrel and prasugrel that bind irreversibly, ticagrelor binds reversibly to the P2Y12 receptor on the surface of platelets. Ticagrelor is not a prodrug and as a result is not subject to potential drug interactions associated with the other agents. Ticagrelor has a more rapid onset and more pronounced platelet inhibition than clopidogrel.
  • Vorapaxar is the first in a new class of antiplatelet agents called protease-activated receptor-1 (PAR-1) antagonists. Vorapaxar has been studied only as an addition to aspirin and/or clopidogrel.

Anticoagulant Agents:

  • There are several oral and injectable anticoagulants commercially available for the management of a variety of medical conditions. The oral anticoagulants include apixaban, dabigatran, edoxaban, rivaroxaban, and warfarin.
  • Warfarin is a vitamin K antagonist that works by interfering with the synthesis of vitamin K dependent clotting factors (II, VII, IX, and X) as well as the anticoagulant proteins C and S. It is available generically and is dosed once daily. Due to its narrow therapeutic window and various food and drug interactions, it requires frequent monitoring of international normalized ratios (INR) to monitor for safety and efficacy. Warfarin does not require dosage adjustments in patients with renal impairment.
  • The direct oral anticoagulants (DOACs) target a single enzyme involved in the coagulation cascade. Dabigatran etexilate mesylate is a prodrug that is converted to dabigatran, a potent, competitive inhibitor of thrombin. Apixaban, edoxaban and rivaroxaban all selectively inhibit factor Xa, thereby preventing the generation of thrombin and ultimately preventing platelet activation and the formation of fibrin clots. These agents require dose adjustments in patients with renal impairment. When used for non-valvular atrial fibrillation, apixaban may be used in severe renal impairment, including patients on hemodialysis.
  • Edoxaban and rivaroxaban are both approved for once-daily dosing (with the exception of the first 21 days for treatment of a deep vein thrombosis [DVT] or pulmonary embolism [PE] with rivaroxaban) whereas dabigatran and apixaban are both administered twice daily. In addition, these DOACs are not associated with the same food and drug interactions as with warfarin treatment. Available antidotes are currently FDA-approved for apixaban, dabigatran, rivaroxaban, and warfarin.
 

 Intravenous/Subcutaneous Anticoagulants
Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes
dalteparin Fragmin test  
enoxaparin Lovenox test   #
fondaparinux Arixtra test   #
heparin test  
heparin lock flush test  

 Oral Anticoagulants
Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes
apixaban Eliquis test  
dabigatran etexilate mesylate Pradaxa test   BP
edoxaban Savaysa PA  
rivaroxaban 10 mg, 15 mg, 20 mg, starter pack Xarelto test  
rivaroxaban 2.5 mg Xarelto PA  
warfarin test  
Table Footnotes
# This designates a brand-name drug with FDA “A”-rated generic equivalents. Prior authorization is required for the brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA “A”-rated generic equivalent.
 
BP Brand Preferred over generic equivalents. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing the non-preferred drug generic equivalent.
 

II. Therapeutic Uses

FDA-approved, for example:

  • Myocardial infarction (Zontivity)
  • Nonvalvular atrial fibrillation (Savaysa)
  • Peripheral artery disease (PAD) (Zontivity)
  • Reduction of risk of major CV events in chronic coronary artery disease (CAD)/PAD (Xarelto 2.5 mg)
  • Treatment of DVT and/or PE (Savaysa)

Note: The above list may not include all FDA-approved indications.

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III.  Evaluation Criteria for Approval

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

  • All PA requests must include clinical diagnosis, drug name, dose, and frequency.
  • A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
  • For recertification requests, approval may require submission of additional documentation including, but not limited to, documentation of: some or all criteria for the original approval; response to therapy; clinical rationale for continuation of use; status of member’s condition; appropriate diagnosis; appropriate age; appropriate dose, frequency, and duration of use for requested medication; complete treatment plan; current laboratory values; and member’s current weight.
  • Additional criteria may apply, depending upon the member’s condition and requested medication (see below).

       

Savaysa

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • appropriate dosing; and
    • compelling clinical rationale for the use of Savaysa instead of other anticoagulants available without prior authorization.

 

Xarelto 2.5 mg

  • Documentation of all of the following is required:
    • diagnosis of reduction of risk of major CV events in chronic CAD/PAD; and
    • member is also receiving concomitant aspirin therapy; and
    • requested quantity ≤ two tablets/day.

    

Zontivity

  • Documentation of all of the following is required: 
    • diagnosis of myocardial infarction or PAD; and
    • requested quantity ≤ one tablet/day; and
    • member does not have a history of stroke or TIA; and
    • member is also receiving aspirin or clopidogrel.

 

†Note: The decision on whether PA is required is based upon information available in the MassHealth medical claim and pharmacy claim databases. The MassHealth database contains member information exclusive to MassHealth, and no other health plans.

Original Effective Date: 01/2012

Last Revised Date: 09/2021

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Last updated 10/25/21

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