Multaq (dronedarone) — Prior Authorization for Reduction of Hospitalization in Atrial Fibrillation
Prior authorization criteria for initial approval of Multaq (dronedarone) to reduce risk of hospitalization for atrial fibrillation in members with a history of non-permanent AF. Applies to prescribers requesting authorization through the payer's pharmacy benefit process.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Prior Authorization
Covered when ALL of the following are met
Authorization duration (DOA): 12 months.
Use for indications other than reduction of hospitalization for atrial fibrillation in patients with a history of paroxysmal or persistent AF is not described as an approved reason for authorization in this document. The FDA-approved indication specifies reduction of hospitalization for atrial fibrillation in patients who are in sinus rhythm with a history of paroxysmal or persistent AF, and requests for other indications are outside the scope of the stated approval.
Use of Multaq (dronedarone) in patients who do not have a history of paroxysmal or persistent (non-permanent) atrial fibrillation, or use for purposes other than to reduce the risk of hospitalization for AF, does not meet the FDA-approved indication and therefore would not satisfy the prior authorization criteria described in this policy.
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