Subject: Multaq PA Policy 532-A 05-2022

Drug

MULTAQ  (dronedarone)

Policy:

FDA-APPROVED INDICATIONS         
Multaq is indicated to reduce the risk of hospitalization for atrial fibrillation in patients in sinus rhythm with a history of paroxysmal or persistent atrial fibrillation (AF). 

COVERAGE CRITERIA
The requested drug will be covered with prior authorization when the following criteria are met:
   •   The requested drug is being prescribed to reduce the risk of hospitalization for atrial fibrillation in a patient with
        a history of paroxysmal or persistent atrial fibrillation (AF), i.e., non-permanent AF

Place of Service:

Outpatient

The above policy is based on the following references:

1. Multaq [package insert]. Bridgewater, NJ: Sanofi-Aventis U.S. LLC; November 2020.
2. Lexicomp Online, AHFS DI (Adult and Pediatric) Online, Hudson, Ohio: UpToDate, Inc.; 2022; Accessed March 23, 2022.
3. Micromedex (electronic version). IBM Watson Health, Greenwood Village, Colorado, USA. Available at: https://www.micromedexsolutions.com. Accessed March 23, 2022.
4. Multaq (dronedarone) Drug Safety Communication. Available at: https://www.fda.gov/drugs/drugsafety/ucm283933.htm. Accessed March 23, 2022.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

October 15, 2022