Cinryze — Medical Mutual

Initial criteria

• The requested medication will not be used concomitantly with other HAE prophylactic therapies (e.g., Cinryze, Haegarda, Takhzyro)
• The requested medication will not be used for acute treatment of hereditary angioedema attacks
• Patient has HAE as confirmed by either: low levels of functional C1-INH protein (< 50% of normal) as defined by lab reference values OR lower than normal serum C4 levels (< 14 mg/dL) AND lower than normal C1-INH level (< 19.9 mg/dL)
• Medication is prescribed by or in consultation with an allergist, immunologist, hematologist, or physician who specializes in HAE or related disorders
• Patient age ≥ 6 years
• Site of care medical necessity is met

Reauthorization criteria

• Patient has HAE as confirmed by either: low levels of functional C1-INH protein (< 50% of normal) as defined by lab reference values OR lower than normal serum C4 levels (< 14 mg/dL) AND lower than normal C1-INH level (< 19.9 mg/dL)
• Medication is prescribed by or in consultation with an allergist, immunologist, hematologist, or physician who specializes in HAE or related disorders
• Patient has had a favorable clinical response (e.g., decrease in duration of HAE attacks, quick onset of symptom relief, complete resolution of symptoms, decrease in attack frequency or severity)
• Reduction in utilization of on-demand therapies used for acute attacks (e.g., Berinert, Ruconest, Firazyr, Kalbitor) while on Cinryze/Haegarda therapy
• Patient age ≥ 6 years
• Site of care medical necessity is met

Approval duration

1 year