- Step Therapy: ST Single Generic
- 1;
- Familial Amyloid Polyneuropathy (FAP):
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Diagnosis Types: 1 of Hereditary transthyretin amyloid cardiomyopathy;Wild type transthyretin amyloid cardiomyopathy
Concomitant Therapy Restrictions: 2 of Oligonucleotide agents (e.g., inotersen);Patisiran (Onpattro)
Required Documentation: 2 of Biopsy results;Radionuclide bone scintigraphy with technetium-labeled bisphosphonates
- Available only through Specialty Pharmacy; May process through Pharmacy or Medical benefit depending on Patient location;
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 drug coverage click HERE;
- Prior Authorization: Assisted Reproductive Technology (ART):
Documented Diagnosis: Yes
Duration: 1 year(s)
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