Coverage Policy
The information displayed below pertains specifically to the Physician Office setting of care. For information tailored to the Hospital Outpatient setting or Pharmacy setting, please select the appropriate tab to the right. Coding, coverage, and reimbursement may vary significantly by payor, plan, patient, and setting of care. See below
Most third-party payors, including HMO plans, managed care organizations, indemnity plans and others provide coverage for FRAGMIN® (dalteparin sodium injection). However, specific coverage requirements and restrictions depend on a patient’s benefits and will vary based on plan type and provider site of service. Some payors have established formal published policies, but the lack of a published policy from a particular payor does not mean that FRAGMIN® is not covered by that payor. In addition, commercial payors may cover FRAGMIN® as a medical benefit, a pharmacy benefit, or both. Each benefit is administered separately and may have different deductible, copayment and/or coinsurance structures. Some commercial insurers may apply coverage and utilization restrictions such as prior authorization or quantity limit edits to FRAGMIN®.
For more information on commercial payor specific coverage of FRAGMIN®, contact your health plan.
Payor Reimbursement
Commercial payor reimbursement for FRAGMIN® may be based on a percent mark-up of Average Sales Price (ASP) similar to Medicare reimbursement methodologies. Payment may also be based on a percent mark-up or mark-down of Average Wholesale Price (AWP) or Wholesale Acquisition Cost (WAC).
Administration Services
Commercial payor reimbursement for physician-related FRAGMIN® drug administration services may be based on a common fee schedule similar to the Medicare reimbursement methodology for physician services or other contracted rates.
Indications
FRAGMIN® is a low molecular weight heparin (LMWH) indicated for:
- Prophylaxis of ischemic complications of unstable angina and non-Q-wave myocardial infarction
- Prophylaxis of deep vein thrombosis (DVT) in abdominal surgery, hip replacement surgery or medical patients with severely restricted mobility during acute illness
- Extended treatment of symptomatic venous thromboembolism (VTE) to reduce the recurrence in patients with cancer. In these patients, the FRAGMIN® therapy begins with the initial VTE treatment and continues for six months.
Limitations of Use
- FRAGMIN® is not indicated for the acute treatment of VTE.
Important Safety Information
Epidural or spinal hematomas may occur in patients who are anticoagulated with low molecular weight heparins (LMWH) or heparinoids and are receiving neuraxial anesthesia or undergoing spinal puncture. These hematomas may result in long-term or permanent paralysis. Consider these risks when scheduling patients for spinal procedures. Factors that can increase the risk of developing epidural or spinal hematomas in these patients include:
- Use of indwelling epidural catheters
- Concomitant use of other drugs that affect hemostasis, such as non-steroidal anti-inflammatory drugs (NSAIDs), platelet inhibitors, other anticoagulants
- A history of traumatic or repeated epidural or spinal punctures
- A history of spinal deformity or spinal surgery
Monitor patients frequently for signs and symptoms of neurological impairment. If neurological compromise is noted, urgent treatment is necessary.
Consider the benefits and risks before neuraxial intervention in patients anticoagulated or to be anticoagulated for thromboprophylaxis [see Warnings and Precautions and Drug Interactions].
- FRAGMIN® is contraindicated in patients with active major bleeding, history of heparin induced thrombocytopenia, hypersensitivity to dalteparin sodium, heparin, or pork products.
- FRAGMIN® is contraindicated in patients undergoing epidural/neuraxial anesthesia as a treatment for unstable angina and non-Q-wave MI and for prolonged VTE prophylaxis due to an increased risk of bleeding associated with the dosage of FRAGMIN® recommended for these indications.
- FRAGMIN®, like other anticoagulants, should be used with extreme caution in patients who have an increased risk of hemorrhage; bleeding can occur at any site during therapy. An unexpected drop in hematocrit or blood pressure should lead to a search for a bleeding site.
- FRAGMIN® should be used with caution in patients with bleeding diathesis, thrombocytopenia or platelet defects, severe liver or kidney insufficiency, hypertensive or diabetic retinopathy, and recent gastrointestinal bleeding.
- FRAGMIN® should be used with extreme caution in patients
with history of heparin-induced thrombocytopenia.
- In FRAGMIN® clinical trials supporting non-cancer indications, platelet count of <50,000/mm3 occurred in <1% of patients.
- In FRAGMIN® clinical trials supporting the extended treatment of symptomatic VTE in patients with cancer, platelet counts of <100,000/mm3 occurred in 13.6% of patients, including 6.5% who also had platelet counts less than 50,000/mm3. In the same clinical trial, thrombocytopenia was reported as an adverse event in 10.9% of patients in the FRAGMIN® arm and 8.1% of patients in the oral anticoagulant arm. FRAGMIN® dose was decreased or interrupted in patients whose platelet counts fell below 100,000/mm3.
- Thrombocytopenia of any degree should be monitored closely. Heparin-induced thrombocytopenia can occur with administration of FRAGMIN®. The incidence of this complication is unknown at present. In clinical practice, rare cases of thrombocytopenia with thrombosis have also been observed.
- Each multiple-dose vial of FRAGMIN® contains benzyl alcohol as a preservative. Benzyl alcohol has been reported to be associated with a fatal "Gasping Syndrome" in premature infants. Because benzyl alcohol may cross the placenta, use caution when administering FRAGMIN® preserved with benzyl alcohol to pregnant women. If anticoagulation with FRAGMIN® is needed during pregnancy, use preservative-free formulations, where possible.
- Periodic routine complete blood counts, including platelet count, blood chemistry, and stool occult blood tests are recommended during the course of treatment with FRAGMIN®.
- The most commonly reported side effect is hematoma at the injection site.
- Allergic reactions (i.e., pruritus, rash, fever, injection site reaction, bulleous eruption) have occurred. A few cases of anaphylactoid reactions have been reported.
- Use FRAGMIN® with care in patients receiving oral anticoagulants, platelet inhibitors, and thrombolytic agents because of increased risk of bleeding.
- FRAGMIN® cannot be used interchangeably (unit for unit) with unfractionated heparin or other low molecular weight heparins.
- FRAGMIN® Injection is not intended for intramuscular administration.
For more information about FRAGMIN, please see Full Product Information.
