Interactive Drug Benefit List
DIN/NPN/PIN 02378612 XARELTO 20 MG ORAL TABLET RIVAROXABAN
200000 BLOOD FORMULATION, COAGULATION AND THROMBOSIS
201200 ANTITHROMBOTIC AGENTS
201204 ANTICOAGULANTS
20120414 DIRECT FACTOR XA INHIBITORS
Date Listed/Coverage Update: 01-Mar-2024
Unit Price: 2.8700
LCA Price: 0.7175
MAC Price:

N/A

Unit of Issue: Tablet
Manufacturer: BAYER INC. (BAI)
ATC: B01AF01
1
Interchangeable Products: Yes

Coverage Status: REGULAR BENEFIT
Applies to Clients of: Non-Group Coverage (Group 1)
Coverage for Seniors (Group 66)
Palliative Coverage (Group 20514, Please note your client may have Group 1 or Group 66 coverage)
Child and Family Services (Group 20403)
Alberta Child Health Benefit (Group 20400)
Children and Youth Services (Group 19824)
Income Support (Group 19823)
Alberta Human Services (AISH) (Group 19823)
Alberta Adult Health Benefit (AAHB) (Group 23609)

Special Authorization Request Form:

N/A

N/A

Review Status / Past Decisions

Indication Reviewing
Body
Submission
Completion
Date
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
CDR
Recommendation
Review
Status
N/A Expert Committee 2024/01/16 2024/03/01 Change to Regular Benefit
PULMONARY EMBOLISM Expert Committee 2015/03/12 2015/05/01 No Special Authorization Criteria Change
PULMONARY EMBOLISM Expert Committee 2015/03/12 2016/01/01 Special Authorization Criteria Change
PULMONARY EMBOLISM Common Drug Review 2013/05/13 2014/07/01 Under Review
PULMONARY EMBOLISM Common Drug Review 2013/05/13 2015/03/01 Special Authorization Criteria Change - Venous Thrombolic Events
PULMONARY EMBOLISM Common Drug Review 2013/05/13 2014/03/26 View CDR - List with clinical criteria and/or conditions
PREVENTION OF STROKE IN PATIENTS WITH A. FIB. Common Drug Review 2013/04/09 2013/07/18 View CDR - List with criteria/condition
DVT (TREATMENT), WITHOUT SYMPTOMATIC PULMONARY EMBOLISM Common Drug Review 2012/10/24 2013/09/01 Special Authorization - DVT Treatment without Symptomatic PE
DVT (TREATMENT), WITHOUT SYMPTOMATIC PULMONARY EMBOLISM Common Drug Review 2012/03/05 2013/06/01 Under Review
DVT (TREATMENT), WITHOUT SYMPTOMATIC PULMONARY EMBOLISM Common Drug Review 2012/03/05 2012/08/16 View CDR - List with criteria/condition
DVT (TREATMENT), WITHOUT SYMPTOMATIC PULMONARY EMBOLISM Common Drug Review 2012/03/05 2013/02/01 Under Review
DVT (TREATMENT), WITHOUT SYMPTOMATIC PULMONARY EMBOLISM Common Drug Review 2012/03/05 2012/11/01 Under Review
DVT (TREATMENT), WITHOUT SYMPTOMATIC PULMONARY EMBOLISM Common Drug Review 2012/03/05 2013/03/01 Under Review
PREVENTION OF STROKE IN PATIENTS WITH A. FIB. Common Drug Review 2011/11/04 2012/10/01 Step Therapy/Special Authorization - AF/Stroke Prevention
PREVENTION OF STROKE IN PATIENTS WITH A. FIB. Common Drug Review 2011/11/04 2012/04/19 View CDR - List with criteria/condition
Indication N/A
Reviewing
Body
Expert Committee
Submission
Completion
Date
2024/01/16
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
2024/03/01
CDR
Recommendation
Review
Status
Change to Regular Benefit
Indication PULMONARY EMBOLISM
Reviewing
Body
Expert Committee
Submission
Completion
Date
2015/03/12
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
2015/05/01
CDR
Recommendation
Review
Status
No Special Authorization Criteria Change
Indication PULMONARY EMBOLISM
Reviewing
Body
Expert Committee
Submission
Completion
Date
2015/03/12
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
2016/01/01
CDR
Recommendation
Review
Status
Special Authorization Criteria Change
Indication PULMONARY EMBOLISM
Reviewing
Body
Common Drug Review
Submission
Completion
Date
2013/05/13
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
2014/07/01
CDR
Recommendation
Review
Status
Under Review
Indication PULMONARY EMBOLISM
Reviewing
Body
Common Drug Review
Submission
Completion
Date
2013/05/13
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
2015/03/01
CDR
Recommendation
Review
Status
Special Authorization Criteria Change - Venous Thrombolic Events
Indication PULMONARY EMBOLISM
Reviewing
Body
Common Drug Review
Submission
Completion
Date
2013/05/13
CDR
Recommendation
Date
2014/03/26
Expert Committee
Recommendation
Date
ADBL
Effective
Date
CDR
Recommendation
View
Review
Status
CDR - List with clinical criteria and/or conditions
Indication PREVENTION OF STROKE IN PATIENTS WITH A. FIB.
Reviewing
Body
Common Drug Review
Submission
Completion
Date
2013/04/09
CDR
Recommendation
Date
2013/07/18
Expert Committee
Recommendation
Date
ADBL
Effective
Date
CDR
Recommendation
View
Review
Status
CDR - List with criteria/condition
Indication DVT (TREATMENT), WITHOUT SYMPTOMATIC PULMONARY EMBOLISM
Reviewing
Body
Common Drug Review
Submission
Completion
Date
2012/10/24
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
2013/09/01
CDR
Recommendation
Review
Status
Special Authorization - DVT Treatment without Symptomatic PE
Indication DVT (TREATMENT), WITHOUT SYMPTOMATIC PULMONARY EMBOLISM
Reviewing
Body
Common Drug Review
Submission
Completion
Date
2012/03/05
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
2013/06/01
CDR
Recommendation
Review
Status
Under Review
Indication DVT (TREATMENT), WITHOUT SYMPTOMATIC PULMONARY EMBOLISM
Reviewing
Body
Common Drug Review
Submission
Completion
Date
2012/03/05
CDR
Recommendation
Date
2012/08/16
Expert Committee
Recommendation
Date
ADBL
Effective
Date
CDR
Recommendation
View
Review
Status
CDR - List with criteria/condition
Indication DVT (TREATMENT), WITHOUT SYMPTOMATIC PULMONARY EMBOLISM
Reviewing
Body
Common Drug Review
Submission
Completion
Date
2012/03/05
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
2013/02/01
CDR
Recommendation
Review
Status
Under Review
Indication DVT (TREATMENT), WITHOUT SYMPTOMATIC PULMONARY EMBOLISM
Reviewing
Body
Common Drug Review
Submission
Completion
Date
2012/03/05
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
2012/11/01
CDR
Recommendation
Review
Status
Under Review
Indication DVT (TREATMENT), WITHOUT SYMPTOMATIC PULMONARY EMBOLISM
Reviewing
Body
Common Drug Review
Submission
Completion
Date
2012/03/05
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
2013/03/01
CDR
Recommendation
Review
Status
Under Review
Indication PREVENTION OF STROKE IN PATIENTS WITH A. FIB.
Reviewing
Body
Common Drug Review
Submission
Completion
Date
2011/11/04
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
2012/10/01
CDR
Recommendation
Review
Status
Step Therapy/Special Authorization - AF/Stroke Prevention
Indication PREVENTION OF STROKE IN PATIENTS WITH A. FIB.
Reviewing
Body
Common Drug Review
Submission
Completion
Date
2011/11/04
CDR
Recommendation
Date
2012/04/19
Expert Committee
Recommendation
Date
ADBL
Effective
Date
CDR
Recommendation
View
Review
Status
CDR - List with criteria/condition
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NOTICE:
The DBL, DBS and related publications require knowledgeable interpretation and are intended primarily for professional health care practitioners, pharmacies, hospitals and organizations associated with the manufacture, distribution and use of pharmaceutical preparations.
Electronic versions of all DBL and DBS related publications are unofficial versions and are provided for convenience and private use only. Official paper versions can be obtained from Alberta Blue Cross who publishes them on behalf of Alberta Health and Alberta Human Services.
Alberta Health reserves the right to make changes, without notice, to the List through the Interactive DBL(iDBL), and any such changes to the Interactive DBL(iDBL) are effective the date of the change (unless otherwise stated) and regardless of the date of publication in the paper version or updates.