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    v1.0.31
    OpenPayerPolicy UpdatesCardiologyAdvanced Health Multaq Prior Auth | OpenPayer
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    CurrentAdvanced HealthPolicy N/A

    Multaq (dronedarone) Drug Use Criteria

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    This policy governs prior authorization and coverage of Multaq (dronedarone) for Oregon Health Plan members. Coverage requires an FDA-approved indication, cardiologist prescribing or supervision, absence of specified high-risk conditions, and failure of or contraindication to amiodarone.

    Policy Summary
    PayerAdvanced Health
    PolicyMultaq (dronedarone) Drug Use Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument an FDA-approved indication, cardiologist involvement, absence of exclusionary conditions, and a failed or contraindicated amiodarone trial before requesting Multaq authorization.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    12 monthsMaximum approval duration
    3Exclusionary conditions triggering denial
    AmiodaroneRequired alternative
    CardiologistRequired specialist

    Coverage Criteria

    Multaq is excluded for members with symptomatic heart failure with recent decompensation requiring hospitalization, NYHA Class IV heart failure, or permanent atrial fibrillation that will not or cannot be cardioverted into normal sinus rhythm. Presence of any one of these conditions results in denial because Multaq increases the risk of death, stroke, and/or heart failure in this population.

    Off-label use of Multaq is not covered under the Oregon Health Plan. Requests must be for an FDA-approved indication; requests for other indications are denied as not meeting coverage criteria.

    Before Multaq can be approved, the member must have tried and failed amiodarone or have a documented contraindication to amiodarone. If neither applies, Multaq is denied as not the least costly alternative and a change to amiodarone is requested.

    Provider Actions and Authorization Risks

    Prior Authorization

    Initial Multaq Authorization

    Prior authorization is required for initial Multaq requests. The request must be for an FDA-approved indication, be prescribed or supervised by a cardiologist, and satisfy the applicable exclusion and amiodarone requirements. If all criteria are met, approval may be granted for up to 12 months.

    Policy Summary
    PayerAdvanced Health
    PolicyMultaq (dronedarone) Drug Use Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument an FDA-approved indication, cardiologist involvement, absence of exclusionary conditions, and a failed or contraindicated amiodarone trial before requesting Multaq authorization.
    SourceLink
    On This Page
    Coverage CriteriaProvider Actions and Authorization RisksPolicy BackgroundDefinitions

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    • FDA-approved indication is required; off-label use is not covered under the Oregon Health Plan.
    • Multaq must be requested by or supervised by a cardiologist.
    • The member must not meet any listed exclusionary cardiac condition.
    • The member must have tried and failed amiodarone or have a contraindication to amiodarone.
    Step Therapy

    Amiodarone Prerequisite

    Before requesting Multaq, document that the member has tried and failed amiodarone or has a contraindication to amiodarone. This step-therapy requirement must be satisfied for approval.

    • Document the prior amiodarone trial and failure, including relevant clinical details; or
    • Document the clinical contraindication to amiodarone.
    Documentation Required

    Required Clinical Documentation

    Submit clinical documentation supporting the request and demonstrating that the authorization criteria are met.

    • FDA-approved indication for Multaq.
    • Prescribing or supervision by a cardiologist.
    • Assessment confirming absence of exclusionary cardiac conditions.
    • Evidence that amiodarone was tried and failed or is contraindicated.
    Denial Risk

    Off-Label Use Not Covered

    Requests for a non-FDA-approved indication will be denied as not meeting criteria. Off-label use of a medication is not a covered benefit under the Oregon Health Plan.

    • Confirm that the requested use is FDA-approved before submitting the request.
    Denial Risk

    Cardiologist Involvement Required

    A request will be denied if Multaq is not being prescribed by or supervised by a cardiologist. Multaq needs to be prescribed and/or monitored by a cardiologist.

    • Document cardiologist prescribing or supervision in the request.
    Denial Risk

    Exclusionary Cardiac Conditions

    A request will be denied if the member has any of the following exclusionary conditions because Multaq increases the risk of death, stroke, and/or heart failure in this population.

    • Symptomatic heart failure with recent decompensation requiring hospitalization.
    • NYHA Class IV heart failure.
    • Permanent atrial fibrillation that will not or cannot be cardioverted into normal sinus rhythm.
    Denial Risk

    Amiodarone Requirement Not Met

    If the member has not tried and failed amiodarone and does not have a contraindication to amiodarone, the request will be denied as not meeting the least costly alternative requirement.

    • Request a change to amiodarone when there is no documented amiodarone failure or contraindication.

    Policy Background

    Multaq (dronedarone) is subject to coverage review for an FDA-approved indication. The medication must be requested by or prescribed under the supervision of a cardiologist; requests without cardiologist involvement do not meet the coverage criteria. The policy also identifies symptomatic heart failure with recent decompensation requiring hospitalization, NYHA Class IV heart failure, and permanent atrial fibrillation that will not or cannot be cardioverted into normal sinus rhythm as exclusionary populations because Multaq increases the risk of death, stroke, and/or heart failure.

    Definitions

    NYHA Class IV heart failure
    DefinitionHeart failure classified as New York Heart Association functional Class IV.
    Permanent atrial fibrillation
    DefinitionAtrial fibrillation that will not or cannot be cardioverted into normal sinus rhythm.