Pradaxa Oral Pellets (dabigatran etexilate oral pellets) — Cigna

Initial criteria

• Venous thromboembolic events, treatment: Patient age ≥ 3 months to < 12 years
• Venous thromboembolic events, to reduce the risk of recurrence: Patient age ≥ 3 months to < 12 years
• Treatment or prevention of other thromboembolic-related conditions: Patient meets BOTH A and B: A) Patient age ≥ 3 months to < 12 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 Pradaxa oral pellets for the treatment of an acute thromboembolic condition

Approval duration

1 year; 6 months for other thromboembolic-related conditions