Sajazir — CareFirst (Caremark)

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 criteria: C1 inhibitor (C1-INH) antigenic level below the lower limit of normal OR normal C1-INH antigenic level and low C1-INH functional level (functional C1-INH less than 50% or below the lower limit of normal as defined by the laboratory)
• OR Member has normal C1 inhibitor as confirmed by laboratory testing AND meets one of the following criteria: Member has an F12, angiopoietin-1, plasminogen, kininogen-1 (KNG1), heparan sulfate-glucosamine 3-O-sulfotransferase 6 (HS3ST6), or myoferlin (MYOF) pathogenic variant confirmed by genetic testing OR Member has a documented family history of angioedema and angioedema was refractory to a trial of high-dose antihistamine therapy (e.g., cetirizine 40 mg per day or equivalent) for at least one month
• Other causes of angioedema have been ruled out (e.g., ACE inhibitor–induced angioedema, estrogen-related angioedema, allergic angioedema)
• Medication prescribed by or in consultation with a prescriber specializing in management of HAE

Reauthorization criteria

• Member continues to meet the initial approval criteria
• Member has experienced a reduction in severity and/or duration of acute attacks
• Prophylaxis considered based on attack frequency, severity, comorbid conditions, and quality of life

Approval duration

12 months