CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Multaq Pa Policy 532 A Udr 05 2024

Prior authorization criteria for Multaq (dronedarone) for reduction of hospitalization risk in patients with a history of paroxysmal or persistent (non-permanent) atrial fibrillation. Includes duration of approval and references.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMultaq Pa Policy 532 A Udr 05 2024

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescriptions for Multaq require prior authorization and will be approved when prescribed to reduce risk of hospitalization for AF in patients with a history of paroxysmal or persistent (non-permanent) AF.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

1Covered Indication(s)

12 moDuration of Approval

Coverage Summary

Coverage stance: covered_with_criteria. Scope: Prior authorization criteria for Multaq (dronedarone) for reduction of hospitalization risk in patients with a history of paroxysmal or persistent (non-permanent) atrial fibrillation — authorization is required and granted only when criteria are met (see initial prior authorization criteria).

Initial Therapy Criteria

Initial Prior Authorization - Atrial Fibrillation (AF)

Authorization may be granted when ALL of the following are met:

Requested drug is Multaq (dronedarone)
Indication: reduce the risk of hospitalization for atrial fibrillation (AF)
AF history: Patient has a history of paroxysmal or persistent atrial fibrillation (i.e., non-permanent AF)

Paroxysmal or persistent AF: Non-permanent atrial fibrillation (history of paroxysmal or persistent atrial fibrillation). This policy aligns prior authorization to the FDA-approved indication for Multaq to reduce the risk of hospitalization for atrial fibrillation in patients in sinus rhythm with a history of paroxysmal or persistent AF.

Provider Actions & Requirements

Prior Authorization

Prior authorization required for Multaq

Prescriptions for Multaq (dronedarone) require prior authorization and will be approved when prescribed to reduce risk of hospitalization for AF in patients with a history of paroxysmal or persistent (non-permanent) AF.

Documentation Required

Document diagnosis and AF history

Providers should document the diagnosis of atrial fibrillation and history specifying paroxysmal or persistent (non-permanent) AF to support prior authorization.

Billing Rule

Duration of approval

Authorized approvals are valid for 12 months (Duration of Approval = 12 months).

Background

Background: Multaq (dronedarone) is FDA-approved to reduce the risk of hospitalization for atrial fibrillation in patients in sinus rhythm with a history of paroxysmal or persistent AF. This policy aligns authorization to that FDA-approved indication. Duration of approval for authorized requests is 12 months.