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Amvuttra (vutrisiran)


Billing

Code: J0225

Description: Inj, vutrisiran, 1 mg

Unit: 1 mg

Payment: $4940.950

Pay quarter: Q3 2023


Medicare history

Dosage and Frequency

Polyneuropathy of hereditary transthyretin-mediated amyloidosis

• 25mg SQ every 3 months

Calculate drug reimbursement


Total Reimbursement:

$130,935.18

(ASP: $123,523.75, Margin: $7,411.43)


Code:

J0225

# Units to bill:

25

Prior Authorization

Prior auth criteria for Amvuttra may include but is not limited to:


1. The patient must be 18 years of age or older.
2. The patient must have documented evidence of hereditary transthyretin-mediated (hATTR) amyloidosis.
3. The patient has been treated with an approved therapy for hATTR amyloidosis and has demonstrated disease progression, as evidenced by neurologic worsening.
4. The patient has polyneuropathy as a primary manifestation of hATTR amyloidosis.
5. The patient is not taking any drugs that may interfere with the activity of Amvuttra.
6. The patient has not experienced any significant adverse effects from any other medications being taken.
7. The patient has a life expectancy of at least 6 months.
8. The patient has provided informed consent for the use of Amvuttra.


Insurance prior auth guidelines:


Billable NDCs

71336-1003-01

Amvuttra (Alnylam Pharmaceuticals, Inc.)

25 MG



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