Andembry — Highmark

Initial criteria

• If the request is for Takhzyro, age ≥ 2 years
• If the request is for Cinryze or Haegarda, age ≥ 6 years
• If the request is for Andembry or Orladeyo, age ≥ 12 years
• Medication is used for prophylaxis management against angioedema attacks of HAE
• Medication is prescribed by or in consultation with an allergist, immunologist, or a provider who specializes in the treatment of hereditary angioedema
• Member has low C4 level ≤ 14 mg/dL or below laboratory reference range AND one of the following: C1INH antigenic level ≤ 19 mg/dL or below laboratory reference range OR normal C1INH antigenic level (≥ 19 mg/dL) with low C1INH functional level (< 50% or below laboratory reference range)
• Member has a history of at least one symptom of moderate or severe angioedema attack (e.g., airway swelling, severe abdominal pain, facial swelling, nausea and vomiting, painful facial distortion) in absence of concomitant hives or use of medication to cause angioedema
• Medications known to cause angioedema (e.g., ACE inhibitors, estrogens, angiotensin II receptor blockers) have been evaluated and discontinued when appropriate
• Member should not be on two prophylactic therapies simultaneously (e.g., Andembry, Cinryze, Haegarda, Orladeyo, Takhzyro)
• If request is for Haegarda, prescriber submits member's weight