Download Use PA form# 20725 for Pradaxa requests

PRADAXA.1
Form # 20725
C:7.12
State of Maine Department of Health &Human Services
MaineCare/MEDEL Prior Authorization Form
PRADAXA (Dabigatran)
www.mainecarepdl.org
Phone: 1-888-445-0497
Member ID #: |__|__|__|__|__|__|__|__|__|
Fax: 1-888-879-6938
Patient Name: ____________________________________ DOB: __________________
(NOT MEDICARE NUMBER)
Patient Address:_________________________________________________________________________________________________
Provider DEA: |__|__|__|__|__|__|__|__|__|
Provider NPI: __|__|__|__|__|__|__|__|__|__|
Provider Name:_______________________________________________________________________ Phone:____________________
Provider Address:_____________________________________________________________________
Fax:____________________
Pharmacy Name:_____________________________Rx Address:________________________________Rx phone:_________________
Provider must fill all information above. It must be legible, correct and complete or form will be returned.
(Pharmacy use only):
NPI: __|__|__|__|__|__|__|__|__|__| NABP: |__|__|__|__|__|__|__| NDC: |__|__|__|__|__|__|__|__|__|__|__|
Drug Name
Strength
Dosage
Instructions
Quantity
Days Supply
PRADAXA
__________
____________
__________
Refills
(34 retail / 90 mail order)
______________
1
2
3
4
5
Medical Necessity Documentation
Current status of patient therapy (check a box & provide clinical justification)
 New to oral anticoagulation therapy
 Continuing Pradaxa therapy
 Switching from warfarin therapy
 Avoiding or switching from injectable anticoagulation
Primary indication for anticoagulation: (Diagnosis of nonvalvular atrial fibrillation without prosthetic heart valve.
CHADS2 score greater than or equal to 2)
 Nonvalvular atrial fibrillation AND
 CHADS2 score 2 or higher (complete page 2)
 Other: __________________________________
Contraindications: (PA will not be approved without clinical justification)







Creatinine clearance < 30 ml/min
< 18 years of age
History of prosthetic heart valve
Has mitral valve disease
Has active pathological bleeding
Is concurrently taking other medications that may increase the risk of bleed, such as but not limited to heparin and
chronic NSAID use.
Not currently taking Rifampin
Please complete both pages of this PA request
1
PRADAXA.1
Form # 20725
C:7.12
Submission of this page is a requirement of prior authorization and serves as documentation of stroke risk.
Risk factor based approach expressed as
a point-based
scoring system, with the acronym
CHADS2 Score
Risk Factors
Score
 Congestive heart
1
failure
 Hypertension
1
(systolic
>160mmHg)
 Age ≥ 75 years
1
 Diabetes mellitus
1
 Stroke / TIA /
2
thrombo-embolism
Annual Stroke Risk based on CHADS2 Score
CHADS2 Score
Stroke Risk %
95%CI
0
1.9
1.2–3.0
1
2.8
2-3
2
4
3.1-5.1
3
5.9
4.6-7.3
4
8.5
6.3-11.1
5
12.5
8.2-17.5
6
18.2
10.5-27.4
CHADS2 Score
Enter CHADS2
Score Here
& Return to Page 1
Maximum possible
score is 6
NOTE: Clinical justification is required when CHADS2 score equals 0 or 1.
Pursuant to the MaineCare Benefits Manual, Chapter I, Section 1.16, The Department regards adequate clinical records as essential for the delivery of quality care, such
comprehensive records are key documents for post payment review. Your authorization certifies that the above request is medically necessary, meets the MaineCare
criteria for prior authorization, does not exceed the medical needs of the member and is supported in your medical records.
Provider Signature: ______________________________________ Date of Submission: _______________________________
*MUST MATCH PROVIDER LISTED ABOVE
Please complete both pages of this PA request
2