Payer PolicyActive
Onpattro (Patisiran)
EVICORE-MEDICAL_DRUG-19A35881
EviCore by Evernorth
Effective: September 1, 2023
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Onpattro (patisiran) is covered for treatment of polyneuropathy due to hereditary transthyretin‑mediated amyloidosis in adults and is excluded for pediatric use, prior liver transplant recipients, and non‑FDA indications. Coverage requires genetic confirmation of hATTR, documented symptomatic polyneuropathy, prescription by or consultation with a neurologist/geneticist/amyloidosis specialist, dosing of 0.3 mg/kg IV every 3 weeks (max 30 mg), and authorization is granted for 12 months.
Coverage Criteria Preview
Key requirements from the full policy
"Onpattro is indicated for the treatment of polyneuropathy of hereditary transthyretin-mediated amyloidosis in adults."
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