Cinryze — CareFirst (Caremark)

Routine prophylaxis against angioedema attacks in adults, adolescents, and pediatric patients (age ≥ 6 years) with hereditary angioedema (HAE)

Initial criteria

The requested medication will not be used in combination with any other medication used for the prophylaxis of hereditary angioedema (HAE) attacks
Member has C1 inhibitor deficiency or dysfunction as confirmed by laboratory testing AND (C1-INH antigenic level below the lower limit of normal OR normal C1-INH antigenic level and a low C1-INH functional level <50% or below the lower limit of normal)
OR Member has normal C1 inhibitor as confirmed by laboratory testing AND (has an F12, angiopoietin-1, plasminogen, kininogen-1 [KNG1], heparan sulfate-glucosamine 3-O-sulfotransferase 6 [HS3ST6], or myoferlin [MYOF] pathogenic variant as confirmed by genetic testing OR has a documented family history of angioedema and angioedema was refractory to a trial of high-dose antihistamine therapy [e.g., cetirizine 40 mg/day] for ≥ 1 month)
Other causes of angioedema (e.g., ACE inhibitor–induced, estrogen-related, allergic) have been ruled out
Prescribed by or in consultation with a prescriber who specializes in management of hereditary angioedema (HAE)

Member meets all initial coverage criteria
Member has experienced a significant reduction in frequency of attacks (e.g., ≥ 50%) since starting prophylactic treatment
Member has reduced the use of medications to treat acute attacks since starting prophylactic treatment

12 months