CINRYZE — Blue Cross Blue Shield of Kansas

Initial criteria

• Medications known to cause angioedema (i.e., ACE inhibitors, estrogens, angiotensin receptor blockers) have been evaluated and discontinued when appropriate
• The prescriber is a specialist in the area of the patient's diagnosis (e.g., allergist, immunologist) or has consulted with a specialist
• The patient will NOT use the requested agent in combination with another agent indicated for prophylaxis of HAE attacks (i.e., Andembry, CINRYZE, HAEGARDA, Orladeyo, TAKHZYRO)
• The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• The patient has been previously approved for the requested agent through the plan's Prior Authorization process
• The prescriber is a specialist in the area of the patient's diagnosis (e.g., allergist, immunologist) or has consulted with a specialist
• The patient has had clinical benefit with the requested agent as indicated by ONE of the following: (A) decrease in the frequency of acute HAE attacks from baseline OR (B) decrease in use of on-demand therapy
• The patient will NOT use the requested agent in combination with another prophylactic HAE agent (i.e., Andembry, CINRYZE, HAEGARDA, Orladeyo, TAKHZYRO)
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

initial 6 months; renewal 12 months