dofetilide — CareFirst (Caremark)

Initial criteria

• Authorization may be granted for the maintenance of, or conversion to, normal sinus rhythm after atrial flutter or atrial fibrillation.
• Authorization may be granted for treatment and prevention of supraventricular tachycardia.
• Authorization may be granted for treatment and prevention of ventricular tachyarrhythmia.

Reauthorization criteria

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

Approval duration

12 months