Ekterly (sebetralstat tablets) — Cigna

Initial criteria

• Patient is age ≥ 12 years; AND
• Patient has HAE type I or type II as confirmed by ALL of the following diagnostic criteria: low levels of functional C1-INH protein (< 50% of normal) at baseline [documentation required]; AND lower than normal serum C4 levels at baseline [documentation required]; AND
• Medication is prescribed by or in consultation with an allergist/immunologist or a physician who specializes in the treatment of HAE or related disorders

Reauthorization criteria

• Patient has a diagnosis of HAE type I or type II [documentation required]; AND
• According to the prescriber, the patient has had a favorable clinical response with Ekterly treatment (e.g., decrease in attack duration, rapid symptom relief, complete resolution of symptoms, or decrease in HAE acute attack frequency or severity); AND
• Medication is prescribed by or in consultation with an allergist/immunologist or a physician who specializes in the treatment of HAE or related disorders

Approval duration

1 year