Payer PolicyActive
Patisiran (Onpattro™)
EVICORE-MEDICAL_DRUG-6FC75AEC
EviCore by Evernorth
Effective: November 1, 2022
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Onpattro (patisiran) is covered only for the FDA‑approved indication—treatment of polyneuropathy due to hereditary transthyretin‑mediated (hATTR) amyloidosis in adults—and non‑FDA uses and patients with prior liver transplantation are excluded. Approval (up to 12 months) requires genetic confirmation of hATTR, documented symptomatic polyneuropathy (e.g., clinical exam/EMG/NCV), age ≥18, prescription by or consultation with an amyloidosis specialist (neurologist/geneticist), and dosing per label 0.3 mg/kg IV every 3 weeks (max 30 mg).
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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