Andembry — Medical Mutual

Initial criteria

• Patient is age ≥ 12 years; AND
• Patient has HAE type I or type II confirmed by BOTH of the following: low levels of functional C1-INH protein (≤ 50% of normal) at baseline AND lower than normal serum C4 levels at baseline; 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; AND
• According to the prescriber, patient has had a favorable clinical response since initiating Andembry prophylactic therapy compared with baseline (examples: decrease in attack frequency, severity, or duration); 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