dabigatran etexilate mesylate capsules (generic Pradaxa) — Cigna

Initial criteria

• Atrial fibrillation (or atrial flutter): Patient age ≥ 18 years
• Deep vein thrombosis or pulmonary embolism, treatment: Patient age ≥ 8 years
• Deep vein thrombosis or pulmonary embolism, to reduce the risk of recurrence: Patient age ≥ 8 years
• Deep vein thrombosis or pulmonary embolism in a patient undergoing hip replacement surgery, prophylaxis: Patient age ≥ 18 years
• Deep vein thrombosis in a patient undergoing knee replacement surgery, prophylaxis: Patient age ≥ 18 years
• Treatment or prevention of other thromboembolic-related conditions: Patient meets BOTH A and B: A) Patient age ≥ 8 years; AND B) ONE of the following (i or ii): i. Patient has tried warfarin, fondaparinux, or a low molecular weight heparin product (e.g., enoxaparin, Fragmin [dalteparin injection]); OR ii. Patient has been started on dabigatran capsules for the treatment of an acute thromboembolic condition

Approval duration

1 year; 60 days for hip or knee replacement prophylaxis; 6 months for other thromboembolic-related conditions