- Prior Authorization: Familial Amyloid Polyneuropathy (FAP):
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
- Available only through Specialty Pharmacy;
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;
- PA Applies
- Quantity Limit: 1 capsule per 1 day(s).
- 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
|