CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Dofetilide (Tikosyn) — Coverage Criteria

Defines covered indications, authorization durations, and continuation requirements for dofetilide (Tikosyn) for members of Neighborhood Health Plan of Rhode Island when approval criteria are met.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDofetilide (Tikosyn) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionRequest authorization for up to 12 months when approval criteria are met; continuation requests must meet all initial authorization criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Primary covered indication groups

12 monthsAuthorization duration

FDA & compendiaSources of indications

Package inserts & guidelinesPrimary references

Coverage Criteria for Dofetilide (Tikosyn)

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.

FDA-approved atrial fibrillation/flutter indications: Use for conversion of atrial fibrillation/atrial flutter to normal sinus rhythm or maintenance (delay in time to recurrence) of normal sinus rhythm in patients with atrial fibrillation/atrial flutter of greater than one week duration who have been converted to normal sinus rhythm.

FDA-approved indications as stated in the labeling.

Compendial uses: Use for ventricular tachyarrhythmia or supraventricular tachycardia as compendial indications.

Compendial uses are covered when approval criteria are met.

Authorization Duration and Continuation

Authorization conditions and duration:

Authorization duration: Authorization of up to 12 months may be granted for maintenance of, or conversion to, normal sinus rhythm after atrial flutter or atrial fibrillation; or for treatment and prevention of supraventricular tachycardia and ventricular tachyarrhythmia when approval criteria are met.12 months

Applies when approval criteria are met.

Continuation of therapy: All members (including new members) requesting authorization for continuation of therapy must meet all initial authorization criteria.

Continuation requests must satisfy initial criteria.

The following uses are excluded from coverage as experimental/investigational: any indication beyond the FDA‑approved indications and the compendial uses listed in this policy. Specifically, compendial uses (such as treatment of ventricular tachyarrhythmia and supraventricular tachycardia) are recognized; all other indications not listed are considered experimental/investigational and are excluded from coverage.

Indications that are not among the FDA‑approved indications or the compendial uses cited in this policy are designated not medically necessary. Requests for dofetilide for purposes outside those specified (i.e., indications not listed above) will be denied as experimental/investigational and not medically necessary.

Provider Requirements and Continuation Rules

Denial Risk

Experimental/Investigational Exclusion

All indications not specifically listed as covered (including compendial uses for atrial flutter/atrial fibrillation, supraventricular tachycardia, and ventricular tachyarrhythmia) are considered experimental/investigational and are not covered.

Non‑listed indications = experimental/investigational → Not covered

Prior Authorization

Authorization Duration and Continuation Requirement

Authorization may be granted for up to 12 months when used for conversion to or maintenance of normal sinus rhythm after atrial flutter or atrial fibrillation, for treatment and prevention of supraventricular tachycardia, or for treatment and prevention of ventricular tachyarrhythmia. Requests for continuation of therapy (including for new members) must meet all initial authorization criteria.

Authorization duration: up to 12 months for covered indications
Continuation requests must satisfy all initial authorization criteria

Documentation Required

Supporting Documentation

Clinical rationale and supporting documentation should be available at the time of request. Acceptable references include FDA‑approved package inserts and recognized clinical resources (e.g., Micromedex). Provide relevant documentation to substantiate the requested indication and demonstrate that all coverage criteria are met.

Include package insert(s) and guideline or compendium references as applicable
Provide clinical notes demonstrating ongoing benefit for continuation requests

Key Definitions

Maintenance of normal sinus rhythm — definition/value

DefinitionDelay in time to recurrence of atrial fibrillation or atrial flutter (AF) in patients with AF of greater than one week duration who have been converted to normal sinus rhythm.

Clinical contextApplied when assessing maintenance of normal sinus rhythm after conversion from AF/atrial flutter; used to determine eligibility for continued antiarrhythmic therapy.

Relevant patient populationPatients with atrial fibrillation or atrial flutter lasting >1 week who have been converted to normal sinus rhythm.

Actionable thresholdPresence of AF/atrial flutter duration >1 week prior to conversion to normal sinus rhythm is required for this definition to apply.

Policy useUsed to define the FDA‑approved maintenance indication for dofetilide (Tikosyn) coverage decisions.

Background

Dofetilide (Tikosyn) is an antiarrhythmic agent referenced in this policy with recognized compendial uses for ventricular tachyarrhythmia and supraventricular tachycardia. Use of dofetilide must align with the covered indications in this policy; uses beyond the FDA‑approved and compendial indications are considered experimental/investigational and are not covered.