CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Pradaxa and Savaysa Prior Authorization Request Form — Coverage Criteria

Prior authorization form and requirements for coverage of Pradaxa (dabigatran) and Savaysa (edoxaban) for Blue Cross Blue Shield - South Carolina members; directs providers on required documentation to support PA requests.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyPradaxa and Savaysa Prior Authorization Request Form — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form (fax 844-403-1029 or via CoverMyMeds) with clinical justification, documentation of prior formulary trials or contraindications, and dosing within guidelines.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2pages in form

>=3required clinical sections

844-403-1029fax

CoverMyMedsreal-time PA portal

855-811-2218PA phone support

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria

inv-01: Initial Authorization — Covered when ALL of the following are met

Covered when ALL of the following are met

Diagnosis: Prescribed for one of the listed indications: prophylaxis of DVT/PE following hip replacement (Pradaxa only); reduction in risk of recurrence of DVT/PE (Pradaxa only); reduction of risk of stroke and systemic embolism in non-valvular atrial fibrillation; treatment of DVT and PE; or other documented diagnosis with ICD-10 code specified.

see form selection

Formulary alternative failure or contraindication: Patient has demonstrated failure or intolerance to a majority (two or more in a class with at least two alternatives or one in a class with only one alternative) of preferred formulary/preferred drug list alternatives (e.g., generic warfarin, Eliquis, Xarelto), OR has a documented contraindication to the listed formulary alternatives; supporting documentation of agents tried, dates, and reasons (or medication name(s) and contraindication) must be provided.

examples include generic warfarin, Eliquis, Xarelto; submit documentation of trials/dates/reasons

Adverse reaction assessment: If the patient has had or is reasonably expected to have an adverse reaction to a majority of the listed formulary agents, documentation of the specific agents and adverse reactions must be provided.

submit medication name(s) and adverse reaction(s)

No appropriate formulary agent available: If applicable, documentation that the patient has a clinical condition for which there is no listed formulary agent to treat the condition based on published guidelines or clinical literature must be provided.

provide clinical condition and supporting literature

Dosing conformity: Prescribed dose must be within the manufacturer's published dosing guidelines or within dosing guidelines found in accepted compendia or current literature (e.g., package insert, AHFS, Micromedex, current accepted guidelines).

prescriber to attest on form

The form does not list any broad exclusions; however, it includes indication-specific limits. For example, selection options explicitly indicate that prophylaxis of DVT/PE following hip replacement and reduction in risk of recurrent DVT/PE apply to Pradaxa only. Other covered indications listed include reduction of risk of stroke and systemic embolism in non-valvular atrial fibrillation, treatment of DVT and PE, and an option to specify Other diagnosis with ICD-10 code.

Providers should be aware that requests may be denied unless all required information is received. The form reminds submitters that incomplete submissions risk denial and provides a contact for prior authorization process questions (phone support).

Diagnosis and Coding

Diagnosis codesICD-10

ICD-10 Code

Field provided for diagnosis ICD-10 code when selecting 'Other diagnosis'

Provider Actions & Prior Authorization

Prior Authorization

Prior Authorization Required — form submission routes

Prior authorization is required. Submit the completed Pradaxa® & Savaysa® Prior Authorization Request Form via the OptumRx fax number or portal listed on the form.

Fax: 844-403-1029
PA phone/help: 855-811-2218 (Mon–Fri 8 a.m.–1 a.m. ET; Sat 9 a.m.–6 p.m. ET)

Documentation Required

Formulary alternative failure / contraindication requirement

The PA form requires documentation that the patient has failed or is intolerant to a majority of preferred formulary alternatives before approval will be considered. "Majority" is defined as two or more agents in a class with at least two alternatives, or one agent in a class with only one alternative.

If yes, submit documentation of medications tried, dates of trials, and reasons for treatment failure.

Initial Therapy Requirements

inv-11: Initial therapy requirements — documentation of indication, prior therapy/contraindication/adverse reactions, dosing within guidelines

Indication selection: Provider selects the appropriate listed indication on the form or specifies 'Other diagnosis' and provides the ICD-10 code.

see Clinical Information section, item 1

Prior therapy documentation: Document failure or intolerance to a majority of preferred formulary alternatives (two or more in a class with at least two alternatives or one in a class with only one alternative) OR document a contraindication to listed formulary alternatives; include medication(s) tried, dates of trials, and reason(s) for treatment failure or details of contraindication.

examples include generic warfarin, Eliquis, Xarelto; submit supporting documentation on form

Adverse reaction documentation: If applicable, provide documentation of any adverse reactions to listed formulary agents, including medication name(s) and the specific adverse reaction(s).

Step Therapy / Trial of Alternatives

Medication tried (name)	Dates of trial	Reason for failure/intolerance/contraindication	Notes / adverse reaction details
(Provider to list specific formulary/preferred agents tried, e.g., generic warfarin, apixaban (Eliquis), rivaroxaban (Xarelto))
(Provider to record start and stop dates for each trial)
(Provider to document reason for treatment failure or intolerance; if contraindication, state specific contraindication)
(Provider to describe any adverse reactions or expected adverse reactions to the listed agents)

Definitions

Definition: "Failure or intolerance to a majority"

DefinitionFailure or intolerance to a majority = two or more agents in a drug class with at least two alternatives, or one agent in a class with only one alternative.

Documentation requiredProviders must submit medication(s) tried, dates of trials, and reason(s) for treatment failure or intolerance.

Examples of preferred formulary alternativesExamples listed on the form include generic warfarin, Eliquis (apixaban), and Xarelto (rivaroxaban).

ApplicabilityApplies to the specific requested indication for anticoagulation as selected on the form (e.g., DVT/PE prophylaxis after hip replacement, reduction in risk of stroke in non‑valvular AF, treatment of DVT/PE, or other documented diagnosis).

Related considerationsIf patient had adverse reactions or is reasonably expected to have adverse reactions to a majority of listed agents, specific agents and reactions must be documented.

Background

This prior authorization form is used to request coverage for the oral anticoagulants Pradaxa (dabigatran) and Savaysa (edoxaban). It captures the requested indication (including specific selections for prophylaxis after hip replacement and reduction in recurrence of DVT/PE that are limited to Pradaxa), documents prior therapy history, contraindications, and adverse reactions to preferred formulary agents, and requires dosing to conform with manufacturer labeling or accepted compendia. The form includes an Other diagnosis field with space for an ICD-10 code when the listed indications do not apply.