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Prior Authorization Criteria for Vutrisiran (Amvuttra) Effective February 1, 2023

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

Effective for dates of service on or after February 1, 2023, prior authorization is required for vutrisiran (Amvuttra), procedure code J0225.

Vutrisiran (Amvuttra) is a transthyretin-directed small interfering ribonucleic acid (RNA) indicated for the treatment of polyneuropathy caused by hereditary transthyretin-mediated (hATTR) amyloidosis in adults.

Prior authorization requests for vutrisiran (Amvuttra) must be submitted with a Special Medicaid Prior Authorization (SMPA) Request Form and may be approved for 12 months per prior authorization request.

Requests for Initial Therapy

For initial therapy, all the following criteria must be met:

  • The client is 18 years of age or older.
  • The client has a diagnosis of hATTR amyloidosis (diagnosis code E851), supported by the following:
  • Transthyretin (TTR) mutation proven by genetic testing
  • Clinical signs and symptoms of the disease (for example, peripheral or autonomic neuropathy and motor disability)
  • The client will not receive vutrisiran (Amvuttra) therapy in combination with other therapies for polyneuropathy caused by hATTR amyloidosis (for example, inotersen, patisiran, or tafamidis meglumine).
  • The client will receive vitamin A supplementation at the recommended daily allowance while on vutrisiran (Amvuttra) therapy.
  • The client has not had a liver transplant.

Requests for Renewal or Continuation of Therapy

For renewal or continuation of therapy, all of the following criteria must be met:

  • The client has previously received treatment with vutrisiran (Amvuttra) without an adverse reaction.
  • The client has a positive clinical response to vutrisiran (Amvuttra) (for example, improved neurologic impairment, improved motor function, or slowing of disease progression.)

For more information, call the TMHP Contact Center at 800-925-9126.