<p> PRADAXA.1 Form # 20725 C:7.12 State of Maine Department of Health &Human Services MaineCare/MEDEL Prior Authorization Form PRADAXA (Dabigatran) Phone: 1-888-445-0497 www.mainecarepdl.org Fax: 1-888-879-6938</p><p>Member ID #: |__|__|__|__|__|__|__|__|__| Patient Name: ______DOB: ______(NOT MEDICARE NUMBER) Patient Address:______</p><p>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: |__|__|__|__|__|__|__|__|__|__|__|</p><p>Dosage Days Supply Drug Name Strength Instructions Quantity (34 retail / 90 mail order) Refills</p><p>PRADAXA ______1 2 3 4 5 Medical Necessity Documentation</p><p>Current status of patient therapy (check a box & provide clinical justification) o New to oral anticoagulation therapy o Continuing Pradaxa therapy o Switching from warfarin therapy o Avoiding or switching from injectable anticoagulation</p><p>Primary indication for anticoagulation: (Diagnosis of nonvalvular atrial fibrillation without prosthetic heart valve. CHADS2 score greater than or equal to 2) o Nonvalvular atrial fibrillation AND o CHADS2 score 2 or higher (complete page 2) o Other: ______</p><p>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 </p><p>Please complete both pages of this PA request</p><p>1 PRADAXA.1 Form # 20725 C:7.12</p><p>Submission of this page is a requirement of prior authorization and serves as documentation of stroke risk.</p><p>Risk factor based approach expressed as a point-based scoring system, with the acronym CHADS2 Score Risk Factors Score o Congestive heart 1 failure o Hypertension 1 (systolic Annual Stroke Risk based on CHADS2 Score >160mmHg) o Age ≥ 75 years 1 CHADS2 Score Stroke Risk % 95%CI o Diabetes mellitus 1 0 1.9 1.2–3.0 o Stroke / TIA / 2 thrombo-embolism 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</p><p>CHADS2 Score</p><p>Enter CHADS2 Maximum possible Score Here score is 6 & Return to Page 1</p><p>NOTE: Clinical justification is required when CHADS2 score equals 0 or 1.</p><p>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.</p><p>Provider Signature: ______Date of Submission: ______*MUST MATCH PROVIDER LISTED ABOVE</p><p>2 PRADAXA.1 Form # 20725 C:7.12</p><p>Please complete both pages of this PA request</p><p>3</p>