PRADAXA.1

Form # 20725

C:7.12

State of Maine Department of Health &Human Services

MaineCare/MEDEL Prior Authorization Form

PRADAXA (Dabigatran)

Phone: 1-888-445-0497 www.mainecarepdl.org Fax: 1-888-879-6938

Dosage Days Supply

Drug Name Strength Instructions Quantity (34 retail / 90 mail order) Refills

PRADAXA ______1 2 3 4 5

Medical Necessity Documentation

Current status of patient therapy (check a box & provide clinical justification)

o  New to oral anticoagulation therapy

o  Continuing Pradaxa therapy

o  Switching from warfarin therapy

o  Avoiding or switching from injectable anticoagulation

Primary indication for anticoagulation: (Diagnosis of nonvalvular atrial fibrillation without prosthetic heart valve. CHADS2 score greater than or equal to 2)

o  Nonvalvular atrial fibrillation AND

o  CHADS2 score 2 or higher (complete page 2)

o  Other: ______

Contraindications: (PA will not be approved without clinical justification)

·  Creatinine clearance 30 ml/min

·  18 years of age

·  History of prosthetic heart valve

·  Has mitral valve disease

·  Has active pathological bleeding

·  Is concurrently taking other medications that may increase the risk of bleed, such as but not limited to heparin and chronic NSAID use.

·  Not currently taking Rifampin

Please complete both pages of this PA request

Submission of this page is a requirement of prior authorization and serves as documentation of stroke risk.

Risk factor based approach expressed as a point-based
scoring system, with the acronym CHADS2 Score
Risk Factors / Score
o  Congestive heart failure / 1
o  Hypertension (systolic >160mmHg) / 1
o  Age ≥ 75 years / 1
o  Diabetes mellitus / 1
o  Stroke / TIA / thrombo-embolism / 2
Annual Stroke Risk based on CHADS2 Score
CHADS2 Score / Stroke Risk% / 95%CI
0 / 1.9 / 1.2–3.0
1 / 2.8 / 2-3
2 / 4 / 3.1-5.1
3 / 5.9 / 4.6-7.3
4 / 8.5 / 6.3-11.1
5 / 12.5 / 8.2-17.5
6 / 18.2 / 10.5-27.4

CHADS2 Score

Enter CHADS2 Maximum possible

Score Here score is 6

& Return to Page 1

NOTE: Clinical justification is required when CHADS2 score equals 0 or 1.

Pursuant to the MaineCare Benefits Manual, Chapter I, Section 1.16, The Department regards adequate clinical records as essential for the delivery of quality care, such comprehensive records are key documents for post payment review. Your authorization certifies that the above request is medically necessary, meets the MaineCare criteria for prior authorization, does not exceed the medical needs of the member and is supported in your medical records.

Provider Signature: ______Date of Submission: ______

*MUST MATCH PROVIDER LISTED ABOVE

Please complete both pages of this PA request

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