- 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): Cardiologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Diagnosis Types: hATTR Amyloidosis with Polyneuropathy
Concomitant Therapy Restrictions: 1 of Oligonucleotide agents (e.g., inotersen);Patisiran (Onpattro)
Required Documentation: 4 of Biopsy results;Documentation of a pathogenic ttR mutation;Documentation of amyloid deposits;Medical Records
Specialist required details: Specialist Consultation
- Quantity Limit: limit maximum 4 EA PER 1 day(s)
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