Anthem Blue Cross (HMO, PPO, EPO)
Pradaxa (dabigatran etexilate)
Drugs for the Blood : Drugs to Prevent Blood Clots
  • Quantity Limit: 2 capsules per 1 day(s).
  • Prior Authorization: Stroke Prevention in Non-valvular Atrial Fibrillation:
    Documented Diagnosis: Yes
    Duration: 1 year(s)

  • Step Therapy: Stroke Prevention in Non-valvular Atrial Fibrillation:
    ST Generic and Brand

  • Stroke Prevention in Non-valvular Atrial Fibrillation:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A


  • For FAX form click HERE
    Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
     Log in to Surescripts
     Log in to CoverMyMeds; For details on quantity limit click  HERE;