Multaq (dronedarone) — Prior Authorization Coverage Criteria
Defines prior authorization criteria for Multaq (dronedarone) when prescribed to reduce risk of hospitalization for atrial fibrillation in patients with a history of paroxysmal or persistent (non-permanent) AF. Applies to prescriptions requiring prior authorization under the payer's pharmacy benefit.
No material clinical or coverage changes in this revision.
Coverage Criteria for Multaq (dronedarone)
Initial Authorization Criteria
Covered when ALL of the following are met
Matches FDA-approved indication per package insert.
Requests for Multaq (dronedarone) for patients who do not have a history of paroxysmal or persistent (non-permanent) atrial fibrillation are outside the stated authorization criteria. Specifically, use in patients with permanent atrial fibrillation or for other indications not described below is excluded from coverage under this policy.
Use of Multaq for any indication other than to reduce the risk of hospitalization for atrial fibrillation in patients with a history of paroxysmal or persistent (non-permanent) AF is not supported by this criteria set and may be denied.
Drug / Policy Identifiers and Codes
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