CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Dofetilide (Tikosyn) — Coverage Criteria and Authorization

Policy governs coverage and authorization criteria for dofetilide (Tikosyn and generic) for FDA‑approved and compendial cardiac indications for members of Neighborhood Health Plan of Rhode Island. It addresses initial and continuation authorization durations and specifies investigational exclusions.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDofetilide (Tikosyn) — Coverage Criteria and Authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization; authorizations of up to 12 months may be granted when all criteria for FDA‑approved or compendial indications are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthstypical authorized duration for approved indications

FDA‑approved + compendialcoverage limited to these uses when criteria met

All other indicationsconsidered experimental/investigational and not medically necessary

Tikosyndrug referenced

Coverage Criteria for Dofetilide (Tikosyn)

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Covered Indications and Authorization Duration

Covered when ALL of the following are met (FDA‑approved indications and compendial uses only):

Root: Coverage is limited to listed FDA‑approved indications and compendial uses; all approval criteria must be met and the member must have no exclusions to the prescribed therapy.

See listed indications and uses.

FDA‑approved indications: Conversion of atrial flutter/atrial fibrillation to normal sinus rhythm OR maintenance of normal sinus rhythm (delay in time to recurrence) in patients with atrial fibrillation of greater than one week duration after conversion.

From FDA‑approved indications.

Compendial uses: Ventricular tachyarrhythmia OR supraventricular tachycardia.

Covered as compendial uses.

Authorization duration: Authorization may be granted for up to 12 months for maintenance or conversion to normal sinus rhythm, and for treatment/prevention of supraventricular tachycardia and ventricular tachyarrhythmia.12 months

Continuation requests (including new members) must meet all initial authorization criteria.

All indications not listed as FDA‑approved or as compendial uses are considered experimental/investigational and are not medically necessary.

Indications other than the listed FDA‑approved indications and the compendial uses (for example, uses beyond ventricular tachyarrhythmia and supraventricular tachycardia) are considered not medically necessary.

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required. Authorizations may be granted for up to 12 months for maintenance therapy or conversion to normal sinus rhythm after atrial flutter or atrial fibrillation, and for treatment and prevention of supraventricular tachycardia or ventricular tachyarrhythmia.

Authorizations up to 12 months for maintenance/conversion or ongoing prevention/treatment

Note

Continuation Requirement

All members (including new members) requesting continuation of therapy must meet all initial authorization criteria. Continuation requests will be reviewed against the same clinical requirements used for initial approvals.

Continuation requests must satisfy all initial authorization criteria
Includes new members

Documentation Required

Required Supporting Documentation

Documentation must support an FDA‑approved or compendial use and include clinical details necessary to establish initial authorization (e.g., indication, prior therapies, response to treatment, and relevant clinical tests). Requests for non‑listed indications are at risk of denial.

Required documentation: indication, prior therapies, treatment response, relevant clinical tests
Use must be FDA‑approved or compendial

Denial Risk

Indication‑based Denial Risk

Requests for indications that are not listed as covered (for example, indications outside the FDA‑approved or compendial uses such as certain ventricular tachyarrhythmia or supraventricular arrhythmias not specified) are at risk of denial.

Non‑listed indications are considered experimental/investigational and may be denied

Approved Indications and Compendial Uses

FDA‑approved indications — Conversion and maintenance of sinus rhythm

IndicationConversion of atrial fibrillation/flutter (AF) to normal sinus rhythm

IndicationMaintenance of normal sinus rhythm (delay in time to recurrence) in patients with AF of >1 week duration after conversion

Authorization durationAuthorizations may be granted for up to 12 months for conversion or maintenance of normal sinus rhythm

Compendial uses

Compendial useVentricular tachyarrhythmia

Compendial useSupraventricular tachycardia

Coverage limitationAll other indications are considered experimental/investigational and not medically necessary