Xarelto (rivaroxaban) Letter of Medical Necessity
Xarelto (rivaroxaban) prior authorization is typically driven by formulary preference for Eliquis. LMNs should address why rivaroxaban is preferred for the specific patient.
FDA-Approved Indications
- ● stroke prevention in non-valvular AFib
- ● DVT/PE treatment and recurrence reduction
- ● CAD/PAD risk reduction
- ● VTE prophylaxis
Why Xarelto Prior Authorization Gets Denied
The most common denial reasons across major payers:
- 1. Eliquis preferred on formulary
- 2. Indication not specified
- 3. Renal function missing
What to Include in a Xarelto Letter of Medical Necessity
Document indication, prior anticoagulant trials, adherence considerations (once-daily vs twice-daily), drug interactions, renal function, and bleeding risk.
Key clinical evidence to cite:
- ✓ ROCKET-AF
- ✓ EINSTEIN-DVT/PE
- ✓ COMPASS
- ✓ VOYAGER PAD
Relevant guidelines:
- 📖 AHA/ACC/HRS 2023 AFib Guidelines
- 📖 CHEST 2021 Antithrombotic Guidelines
Xarelto Prior Authorization Criteria
Standard criteria across major US payers for Xarelto. Specific criteria vary by plan — RxCheckUp tailors each LMN to your patient's exact payer policy.
Typical step therapy requirements:
- → Documented failure or contraindication to formulary alternatives
Required documentation:
- ✓ ICD-10 diagnosis code with specificity
- ✓ Prior therapy history with dates, doses, and discontinuation reasons
- ✓ Specialist evaluation (where applicable)
- ✓ Baseline disease activity or biomarker results
- ✓ Clinical rationale citing FDA labeling or guidelines
Approval details:
Initial approval: typically 6 months. Renewal: 12 months with documented clinical response.
Payers Covering Xarelto
RxCheckUp tailors each LMN to the specific payer's medical policy and step therapy requirements:
Xarelto Prior Authorization FAQ
Why was my Xarelto prior authorization denied?
The most common denial reasons for Xarelto are: Eliquis preferred on formulary; Indication not specified; Renal function missing.
What should a Xarelto Letter of Medical Necessity include?
Document indication, prior anticoagulant trials, adherence considerations (once-daily vs twice-daily), drug interactions, renal function, and bleeding risk.
Which payers cover Xarelto?
Xarelto is covered by major US payers including Medicare Part D, UnitedHealthcare, Aetna, Cigna, BCBS, though formulary tier and prior authorization criteria vary.