ACORAMIDIS (ATTRUBY)

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 (heart disease) associated with wild type or hereditary transthyretin-mediated amyloidosis (ATTR: a rare genetic disorder) which is confirmed by documentation of ONE of the following:
   1. Imaging
   2. Histological testing
   3. Genetic testing
2. You are 18 years of age or older
3. Your doctor attests that you will NOT be used with any other transthyretin silencer(s) or stabilizer(s) (such as, Attruby, Onpattro, Vyndaqel, Vyndamax, Waiuna)
4. The requested dose does not exceed 1,424 mg (4 capsules) daily

RENEWAL CRITERIA

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

1. You have history of the requested agent in the past 90 days
2. Your doctor attests that you will NOT be used with any other transthyretin silencer(s) or stabilizer(s) (such as, Attruby, Onpattro, Vyndaqel, Vyndamax, Waiuna)
3. The requested dose does not exceed 1,424 mg (4 capsules) daily