- Familial Amyloid Polyneuropathy (FAP):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Diagnosis Types: hATTR Amyloidosis with Polyneuropathy
Concomitant Therapy Restrictions: 2 of Oligonucleotide agents (e.g., inotersen);Tafamidis meglumine
Required Documentation: Documentation of a pathogenic ttR mutation
- Quantity Limit: limit maximum 0.72 mL PER 1 day(s)
- PA Applies
- 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;
|