Pradaxa Oral Pellets — Medical Mutual
Treatment or Prevention of Other Thromboembolic-Related Conditions
Initial criteria
- Patient is age ≥ 3 months to < 12 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 Pradaxa oral pellets for the treatment of an acute thromboembolic condition
- Patient has had a trial of Eliquis or Xarelto OR Patient is currently receiving Pradaxa oral pellets
Reauthorization criteria
- Continuation requires response to therapy unless otherwise noted
Approval duration
6 months