Representatives from the ACC and American Society of Hematology (ASH) recently met with CVS Caremark regarding the decision to prefer rivaroxaban over other direct oral anticoagulants (DOACs) and its potential impact on existing patients, citing significant concerns with limiting patient-physician medication choice, as well as increased administrative burden and likely treatment delays associated with the existing formulary exception process.

According to CVS Caremark, the decision is limited to a non-Medicare aged commercial value plan and was based on current medical specialty guidelines, including the 2019 Focused Update of the AHA/ACC/HRS Atrial Fibrillation Guideline, as well as cost considerations. They also noted a lack of randomized controlled trial comparison data among the DOACs. The decision does not include all prescription plans.

Both the ACC and ASH underscored the negative impacts of this decision on patients currently taking one of the non-preferred DOACs and on those who have previously tried rivaroxaban and changed medications. They also highlighted the difficulties with other prior authorization programs related to the need for dedicated staff, time away from direct patient care and often delayed patient care.

The groups also stress that while the 2019 guideline update does not tier DOACs, the intent of the document is to encourage discussion between physicians and patients so an informed decision on the most appropriate medication can be made based on medical history and preferences. Similarly, while ASH's 2020 guideline for management of venous thromboembolism encourages the use of DOACs in certain clinical scenarios, the document outlines several factors to consider when determining the specific DOAC for an individual patient. Those factors include renal function, concomitant medications and presence of cancer, as well as patient preference for once or twice-daily dosing and out-of-pocket costs.

The ACC and ASH will continue discussions with CVS Caremark regarding the burden on clinicians and the effect of the decision on patient access. In the meantime, prescribers can request a formulary exception for those clinically appropriate patients. To help patients avoid gaps in therapy, CVS Caremark advises that prescribers:

• Submit requests through the electronic prescribing (e-prescribing) process for faster decision-making.
• Remind patients who encounter an issue accessing their necessary medications to call the number on the back of their CVS Caremark prescription ID card.
• Note that the patient's pharmacy can request a one-time override for trying to fill a non-preferred DOAC in January when more time is needed to either make the change with their health care provider or request a formulary exception.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiovascular Care Team, Pulmonary Hypertension and Venous Thromboembolism, Anticoagulation Management and Atrial Fibrillation, Anticoagulation Management and Venothromboembolism, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Atrial Fibrillation, Rivaroxaban, Venous Thromboembolism, Prior Authorization, Anticoagulants, Hematology, Pharmacy, Pyridones, Pyrazoles, ACC Advocacy

< Back to Listings