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FSSA/OMPP wants to make Medicaid better for members and they need your help. Apply to join Indiana Medicaid’s NEW Beneficiary Advisory Council (BAC) to share your experience. The BAC, composed of current and former Medicaid members and caretakers, will discuss policy and program changes. To apply, complete the BAC application and submit it via email or mail. Additionally, here is the website link for the FSSA BAC page: https://www.in.gov/fssa/ompp/advisory-committees/beneficiary-advisory-council

Generic Brand HICL GCN Exception/Other

ACORAMIDIS

ATTRUBY

50022

 

 

Guidelines for Use

INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW)

Our guideline named ACORAMIDIS (Attruby) requires the following rule(s) be met for approval:

  1. You have cardiomyopathy associated with wild type or hereditary transthyretin-mediated amyloidosis (ATTR-CM: heart disease caused by a build-up of a type of protein) which is confirmed by documentation of ONE of the following:
    1. Biopsy
    2. Imaging
    3. Histological analysis
    4. Genetic testing
  2. You are 18 years of age or older
  3. The requested agent is prescribed by or in consultation with a cardiologist

RENEWAL CRITERIA

Our guideline named ACORAMIDIS (Attruby) requires the following rule(s) be met for renewal:

  1. You have history of paid claim(s) for the requested medication in the past 90 days
Created: 4/11/2025 2:02:07 PM


Last Modified: Thursday, May 1, 2025