Download carta circular - Cartas Circulares – Triple

Carta Circular #M1511192
20 de noviembre de 2015
Página 1
CARTA CIRCULAR #M1511192
30 de noviembre de 2015
A TODOS LOS MÉDICOS PARTICIPANTES DE TRIPLE-S SALUD
POLÍTICA DE PAGO DEL MEDICAMENTO XARELTO® (RIVAROXABAN 15mg, 20mg)
Esta carta sustituye la # M1507099 del 24 de julio de 2015. Triple-S cubrirá el medicamento
Xarelto® (Rivaroxaban 15mg, 20mg) para aquellos asegurados cuya cubierta de farmacia
incluya este medicamento. La política establecida en esta carta circular aplicará a los pacientes
que utilicen Xarelto® (Rivaroxaban 15mg, 20mg) a partir de la fecha de emisión de esta carta
circular.
Los siguientes criterios se requieren sean documentados en la receta. También se adjunta la
hoja de preautorización para completar el proceso de evaluación.
A) DIAGNÓSTICO:
 Fibrilación Atrial No Valvular (ICD-9 427.31, ICD-10 I48.0, I48.2 I48.91)
 Tratamiento de trombosis de vena profunda (ICD-9: 453.40, ICD10:
I82.401, I82.402, I82.403, I82.409) y embolismo pulmonar (ICD-9:
415.1, ICD10: I26.9, I26.99, T81.72XA)
 Reducción de riesgo de recurrencia de trombosis de vena profunda
(ICD-9: 453.40, ICD10: I82.409) y embolismo pulmonar (ICD-9: 415.1,
ICD10: T81.72XA)
 NOTA: La siguiente indicación no estará sujeta a documentar la
información provista en el formulario de preautorización:

Profilaxis de trombosis de vena profunda que puede llevar a
embolismo pulmonar en pacientes que hayan tenido una cirugía
de reemplazo de cadera o rodilla.
B) DOCUMENTAR:
 Paciente no presenta sangrado activo
 Paciente no tiene una válvula cardiaca prostética
Carta Circular #M1511192
20 de noviembre de 2015
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 Valor de creatinina sérica reciente
 Paciente con Fibrilación Atrial No Valvular presenta por lo menos uno de los
siguientes:

Historial de derrames cerebrales, ataque isquémico transitorio (TIA) (ICD-9:
434-435; ICD10: I63.3, I63.4, I63.5, G49.9)

CHA2DS2-VASc de 2 o más.
 Para el tratamiento de DVT y PE

Largo de la terapia
IMPORTANTE este cambio no aplica a:



Programas de Triple-S Advantage
Planes de Cuidado Coordinado (AXIS, CCI) y algunos planes comerciales.
Asegurados del Plan de Salud de Gobierno de Puerto Rico (PSG)
Si necesita información adicional, comuníquese con nuestro Departamento de Gerencia de
Servicio al 787-749-4700 o al 1-877-357-9777 (para llamadas de larga distancia, libre de
cargos).
Cordialmente,
Soraya Conde Rivera, MBA, R.Ph
Director
Departamento de Farmacia
Unidad de Gerencia Clínica
Ángela T. Hernández Michels, MD
Director Médico Asociado
División de Asuntos Médicos y Dentales
Request Form for Xarelto® (Rivaroxaban)
Pharmacy Department 787-774-4832 (Fax)
Physician Information
Name: ___________________________________________________________________________________
# License: ________________________ Physician specialty: _______________________________________
Address: _________________________________________________________________________________
Telephone: ______________________
Fax: ___________________________________________________
Patient General Information
Name: ______________________________________
Member ID: _________________________________
Date of birth:__________________________________
Address:____________________________________
Sex:
□ M □F
___________________________________________
Weight:______ Height:_______
Medication requested
□ Xarelto
®
(Rivaroxaban) Dose: ______________
Sig: ____________________________________
Medical Information
Please answer the following questions:
1) Please indicate for which of the following indications
rivaroxaban will be prescribed:
□ To reduce the risk of stroke and systemic embolism
in patients with non-valvular atrial fibrillation (ICD-10
I48.0, I48.2., I48.91)
□ For the treatment of deep venous thrombosis (DVT)
(ICD-10 I82.401, I82.402, I82.403, I82.409) and
pulmonary embolism (PE) (ICD-10 I26.9, I26.99,
T81.72XA) in patients who have been treated with a
parenteral anticoagulant for 5 -10 days
□ To reduce the risk of recurrence of DVT (ICD-10
I82.409) and PE (ICD-10 T81.72XA) in patients who
have been previously treated
□ For the prophylaxis of deep vein thrombosis, which
2) For patients of non-valvular atrial fibrillation, please
indicate if the patient presents any of the following:
□ TIA
□ Prior stroke
□ CHA2DS2-VASc score of 2 or greater
□ Other (Please specify)
3) Please indicate if the patient has any of the following:
Active pathological bleeding
 Yes
 No
Prosthetic heart valve
 Yes
 No
may lead to pulmonary embolism, in patients who have
4) For the treatment of DVT and PE please indicate:
undergone hip or knee replacement surgery (Not need
continue documentation)
Length of therapy: _________________
Please provide any medical information which may support approval: (optional)
□
Physician signature:
Date:
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