Prior Authorization Criteria Update for Amvuttra

Date: December 29, 2022

Attention: All Providers

Effective date: February 1, 2023

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: Effective, February 1,2023, the Texas Health and Human Services Commission (HHSC) will update the prior authorization criteria for Amvuttra (procedure code J0225).

Amvuttra (vutrisiran) is a transthyretin-directed small interfering RNA indicated for the treatment of the polyneuropathy of hereditary transthyretin-mediated (HATTR) amyloidosis in adults.

How this impacts providers: Members must meet the following criteria for approval for 12 months:

Initial Requests

1.  Member is 18 years of age or older
2. Diagnosis of hereditary transthyretin (hATTR) amyloidosis (diagnosis code: 5.1), supported by
   1. Transthyretin (TTR) mutation proven by genetic testing
3. Clinical signs and symptoms of the disease (e.g., peripheral/autonomic neuropathy, motor disability)
4. Member will not receive Amvuttra (vutrisiran) therapy in combination with other polyneuropathy hATTR amyloidosis therapies (e.g., inotersen, tafamidis meglumine or patisiran).
5. Member will receive vitamin A supplementation at the recommended daily allowance while on Amvuttra (vutrisiran) therapy.
6.  Member has not had a liver transplant.

Renewal or Continuation Therapy

1. Member has previously received treatment with Amvuttra (vutrisiran) without an adverse reaction.
2. Member has a positive clinical response to Amvuttra (e.g., improved neurologic impairment, improved motor function, slowing of disease progression).

Next steps for providers: Providers should share this communication with their staff. Refer to the Outpatient Drug Services Handbook Chapter of the Texas Medicaid Provider Procedure Manual (TMPPM) for more details on the clinical policy and prior authorization requirements.

If you have any questions, please email TCHP Pharmacy at: TCHPPharmacy@texaschildrens.org.

For access to all provider alerts,log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.