Medicare AdvantagePrior AuthMedium impact
Pradaxa® (dabigatran etexilate) oral pellet (Revised)
Humana·Pediatrics, Hematology, Pharmacy·Medicare Advantage
Effective date
Apr 26, 2023
We identified it
Jun 25, 2026
Summary
This is a revised Humana Medicare Advantage prior authorization policy for Pradaxa® (dabigatran etexilate) oral pellet, a direct thrombin inhibitor for treating venous thromboembolism (VTE) in pediatric patients aged 3 months to less than 12 years. The policy requires prior authorization and mandates that members must have either acute VTE treatment with parenteral anticoagulant for ≥5 days OR prior VTE history, AND prior failure/contraindication/intolerance to specific alternative anticoagulants (Xarelto oral suspension, Eliquis apixaban sprinkle capsule, or Eliquis apixaban tablet suspension) before approval.
Action Required
REQUIREMENTS:
- Immediately: Billing team and pharmacy staff must implement prior authorization requirement for all Pradaxa oral pellet claims under Humana Medicare Advantage plans.
- Update billing system and pharmacy management software to flag Pradaxa oral pellet prescriptions for prior authorization submission before processing.
- Billing team must verify BOTH criteria are documented before claim submission: (1) VTE diagnosis with ≥5 days parenteral anticoagulant therapy OR prior VTE history, AND (2) documented prior therapy/contraindication/intolerance to Xarelto oral suspension, Eliquis apixaban sprinkle capsule, or Eliquis apixaban tablet suspension.
- Provider/clinical staff must include documentation of failed alternative anticoagulants in prior authorization request to Humana.
- Do NOT process claims without prior authorization approval—claims will be denied.
- Alert providers to the Black Box Warning regarding premature discontinuation risk and the need for continuous anticoagulation coverage to prevent thrombotic events.
- For pediatric patients only: Ensure age verification (3 months to <12 years) before authorization submission.