- Prior Authorization: Familial Amyloid Polyneuropathy (FAP):
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
Reauthorization Required: Yes
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;
- Quantity Limit: 4 syringes per 28 day(s).
- PA Applies
- Familial Amyloid Polyneuropathy (FAP):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Neuropathy Impairment Score: Other Polyneuropathy Disability
Diagnosis Types: hATTR Amyloidosis with Polyneuropathy
Concomitant Therapy Restrictions: 2 of Patisiran (Onpattro);Tafamidis meglumine
Required Documentation: 4 of Baseline Platelet Count;Documentation of a pathogenic ttR mutation;Genetic Mutation;urinary protein to creatinine ratio (UPCR)
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