Haegarda — Cigna

Initial criteria

• Patient has HAE type I or type II as confirmed by BOTH of the following: a) Patient has low levels of functional C1-INH protein (< 50% of normal) at baseline [documentation required]; AND b) Patient has lower than normal serum C4 levels at baseline [documentation required]
• 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]
• According to the prescriber, the patient has had a favorable clinical response since initiating Haegarda prophylactic therapy compared with baseline (e.g., decrease in HAE attack frequency, severity, or duration)
• 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