Payer PolicyActive
Patisiran (Onpattro)
EVICORE-MEDICAL_DRUG-D97F0235
EviCore by Evernorth
Effective: August 1, 2019
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Covered only for the FDA‑approved indication: treatment of the polyneuropathy of hereditary transthyretin‑mediated (hATTR) amyloidosis in adults (no off‑label uses); approval is for 12 months with dosing 0.3 mg/kg IV every 3 weeks (maximum 30 mg). Key requirements: genetic confirmation of hATTR, documented symptomatic peripheral neuropathy, age ≥18, prior or current trial of a gabapentin‑type agent or a tricyclic antidepressant, prescription or consultation by a neurologist/geneticist/amyloidosis specialist, and supporting documentation.
Coverage Criteria Preview
Key requirements from the full policy
"Documentation of age demonstrating the patient is at least 18 years of age."
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