(formerly WellFirst Health)
Coverage of any drug intervention discussed in a Medica prior authorization
guideline is subject to the limitations and exclusions outlined in the member's
benefit certificate or policy and applicable state and/or federal laws.
Individual and family products in Missouri underwritten by Medica Central Insurance Company. Individual and family products in Illinois,
and Medicare Advantage policies in Missouri and Illinois, are provided by Medica Central Health Plan. Third- party administration
services provided by Dean Health Service Company, LLC. All products, policies and services are branded as Medica.
ANDEXXA (andexanet alfa) 1 of 3
☒ Commercial (Small & Large Group) ☒ ASO ☒ Exchange/ACA
☐ Medicare Advantage (MAPD)
ANDEXXA (andexanet alfa) MB1843
Covered Service:
Yes
Prior Authorization
Required:
No
Additional
Information:
None
Medicare Policy:
Prior authorization is not required for Medicare Cost products
(Dean Care Gold) and Medicare Supplement (Select) when this
drug is provided by participating providers. Prior authorization is
required if a member has Medicare primary and the plan
secondary coverage. This policy is not applicable to our
Medicare Replacement products.
Wisconsin
Medicaid Policy
Coverage of prescription drug benefits is administered by the
Wisconsin Medicaid program. Coverage of medical drug benefits
is administered by the Wisconsin Medicaid fee-for-service
program. Medical drugs not paid on a fee-for-service basis by the
Wisconsin Medicaid program are covered by the plan with no PA
required.
Plan Approved Criteria:
1.0 Injections of drugs that are administered at an excessive frequency or dose are not
medically necessary. Frequency or dosing are considered excessive when services
are performed more frequently or at a higher dose than listed in the FDA-approved
package insert, listed in this document or generally accepted by peers and the reason
for additional services is not justified by submitted documentation of clinical evidence.
Route of administration of injectable drugs should follow the FDA-approved package
insert.
(formerly WellFirst Health)
Coverage of any drug intervention discussed in a Medica prior authorization
guideline is subject to the limitations and exclusions outlined in the member's
benefit certificate or policy and applicable state and/or federal laws.
Individual and family products in Missouri underwritten by Medica Central Insurance Company. Individual and family products in Illinois,
and Medicare Advantage policies in Missouri and Illinois, are provided by Medica Central Health Plan. Third- party administration
services provided by Dean Health Service Company, LLC. All products, policies and services are branded as Medica.
ANDEXXA (andexanet alfa) 2 of 3
2.0 ANDEXXA (andexanet alfa) is considered medically appropriate when all of the
following is met:
2.1 Member is treated with rivaroxaban or apixaban and requires reversal of
anticoagulation due to life-threatening or uncontrolled bleeding; AND
2.2 The last dose of anticoagulant was given ≤18 hours prior to presentation; AND
2.3 Member is not scheduled to undergo surgery in less than 12 hours with the
exception of minimally invasive surgeries or procedures; AND
2.4 No recent history (within two weeks) of a diagnosed thrombotic event; AND
Comments:
1.0 Codes and descriptors listed in this document are provided for informational purposes
only and may not be all inclusive or current. Listing of a code in this drug policy does
not imply that the service described by the code is a covered or non-covered service.
Benefit coverage for any service is determined by the member’s policy of health
coverage with the plan. Inclusion of a code in the table does not imply any right to
reimbursement or guarantee claim payment. Other drug or medical policies may also
apply.
1.1 NDC and HCPCS codes
Medication Name
How Supplied
National Drug
Generic
Code (NDC)
HCPCS code
andexanet alfa
Single-use vial:
100 mg
69835-0101-01
J7169
2.0 NOTE: The use of physician samples or manufacturer discounts does not
guarantee later coverage under the provisions of the medical certificate and/or
pharmacy benefit. All criteria must be met in order to obtain coverage of the
listed drug product.
Committee/Source
Date(s)
Document
Created:
Medical Policy Committee/Health Services
Division/Pharmacy Services
December 19, 2018
(formerly WellFirst Health)
Coverage of any drug intervention discussed in a Medica prior authorization
guideline is subject to the limitations and exclusions outlined in the member's
benefit certificate or policy and applicable state and/or federal laws.
Individual and family products in Missouri underwritten by Medica Central Insurance Company. Individual and family products in Illinois,
and Medicare Advantage policies in Missouri and Illinois, are provided by Medica Central Health Plan. Third- party administration
services provided by Dean Health Service Company, LLC. All products, policies and services are branded as Medica.
ANDEXXA (andexanet alfa) 3 of 3
Committee/Source
Date(s)
Revised:
Medical Policy Committee/Health Services
Division/Pharmacy Services
Medical Policy Committee/Health Services
Division/Pharmacy Services
Medical Policy Committee/Health Services
Division/Pharmacy Services
November 20, 2019
July 15, 2020
November 17, 2021
Reviewed:
Medical Policy Committee/Health Services
Division/Pharmacy Services
Medical Policy Committee/Health Services
Division/Pharmacy Services
Medical Policy Committee/Health Services
Division/Pharmacy Services
Medical Policy Committee/Health Services
Division/Pharmacy Services
Medical Policy Committee/Health Services
Division/Pharmacy Services
November 20, 2019
July 15, 2020
November 18, 2020
November 17, 2021
November 16, 2022
Published: 12/01/2022
Effective: 12/01/2022
References:
1. Andexxa [prescribing information]. Alexion Pharmaceuticals, Inc. Boston, MA.
Accessed November 2021.