- Prior Authorization: Familial Amyloid Polyneuropathy (FAP):
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Familial Amyloid Polyneuropathy (FAP):
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Neurologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Neuropathy Impairment Score: 1 of Baseline FAP Stage 1 or 2;Baseline polyneuropathy disability (PND) score <= IIIb;Neuropathy Impairment Score =>10 and <=130
Diagnosis Types: hATTR Amyloidosis with Polyneuropathy
Concomitant Therapy Restrictions: 1 of Patisiran (Onpattro);Vyndamax;Vyndaqel
Required Documentation: Documentation of a pathogenic ttR mutation
Specialist required details: Specialist Consultation
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