dabigatran etexilate mesylate capsules — Medical Mutual

Initial criteria

• Patient is age ≥ 8 years
• Patient meets ONE of the following: (i) Patient has tried warfarin, fondaparinux, or a low molecular weight heparin product (e.g., enoxaparin, dalteparin injection); OR (ii) Patient has been started on dabigatran capsules for the treatment of an acute thromboembolic condition

Reauthorization criteria

• Continuation requires response to therapy unless otherwise noted

Approval duration

6 months