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NC Pharmacy Prior Approval Request forMedications for Duchennes Muscular Dystrophy Vyondys 53 and Viltepso Beneficiary Information 1. Beneficiary Last Name: ___ 2. First Name: ___ 3. Beneficiary ID

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To fill out Vyondys 53 Viltepso North, follow these steps:

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Obtain the Vyondys 53 Viltepso North prescription from a healthcare professional.

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Complete the patient's personal information section, including name, date of birth, address, and contact details.

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Provide the healthcare professional's details, including name, address, and contact information.

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Fill out the dosage and administration section as instructed by the healthcare professional.

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Vyondys 53 Viltepso North is primarily prescribed for individuals with Duchenne muscular dystrophy who have a confirmed mutation of the dystrophin gene amenable to exon 53 skipping.

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This medication is intended for patients who are aged 5 years and older.

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