Ruconest — CareFirst (Caremark)

Treatment of acute attacks in adult and adolescent patients with hereditary angioedema (HAE)

Initial criteria

Medication will not be used in combination with any other medication used for the treatment of acute HAE attacks
Member has C1 inhibitor deficiency or dysfunction as confirmed by laboratory testing AND meets one of the following: C1 inhibitor (C1‑INH) antigenic level below the lower limit of normal as defined by the laboratory performing the test OR normal C1‑INH antigenic level and a low C1‑INH functional level (functional C1‑INH less than 50% or C1‑INH functional level below the lower limit of normal as defined by the laboratory performing the test)
OR member has normal C1 inhibitor as confirmed by laboratory testing AND either (a) 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 (b) has documented family history of angioedema and angioedema was refractory to a trial of high‑dose antihistamine therapy (cetirizine 40 mg/day or equivalent) for at least one month
Other causes of angioedema (e.g., ACE inhibitor‑induced angioedema, estrogen‑related angioedema, allergic angioedema) have been ruled out
Prescriber is a specialist or in consultation with a specialist in management of hereditary angioedema

Member continues to meet all requirements in the coverage criteria section
Member has experienced a reduction in severity and/or duration of acute attacks
Prophylaxis considered based on attack frequency, attack severity, comorbid conditions, and member’s quality of life

12 months