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 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