Health Net
Vyndaqel (tafamidis meglumine)
Hormones : Hormones
  • Prior Authorization: Familial Amyloid Polyneuropathy (FAP):
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Reauthorization Required: Yes

  • Familial Amyloid Polyneuropathy (FAP):
    Age Requirement: >= 18
    Duration: 6 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: Hereditary transthyretin amyloid cardiomyopathy
    Required Documentation: 4 of Biopsy results;Documentation of a pathogenic ttR mutation;Documentation of amyloid deposits;Genetic Mutation
    Specialist required details: Specialist Consultation

  • Quantity Limit: limit maximum 4 EA PER 1 day(s)