Berinert (C1 esterase inhibitor [human]) — United Healthcare

Treatment of acute abdominal, facial, or laryngeal hereditary angioedema (HAE) attacks

Preferred products

Diagnosis of hereditary angioedema (HAE) as confirmed by one of the following:
C1 inhibitor (C1-INH) deficiency or dysfunction (Type I or II HAE) as documented by one of the following (per laboratory standard):
C1-INH antigenic level below the lower limit of normal OR C1-INH functional level below the lower limit of normal
OR
HAE with normal C1 inhibitor levels and one of the following:
Confirmed presence of variant(s) in the gene(s) for factor XII, angiopoietin-1, plasminogen-1, kininogen-1, myoferlin, or heparan sulfate-glucosamine 3-O-sulfotransferase 6
Recurring angioedema attacks that are refractory to high-dose antihistamines with confirmed family history of angioedema
Recurring angioedema attacks that are refractory to high-dose antihistamines with unknown background de-novo mutation(s) (i.e., no family history) (HAE-unknown)
AND
Prescribed for the acute treatment of HAE attacks
AND
Not used in combination with other products indicated for the acute treatment of HAE attacks (e.g., Firazyr, Ruconest)
AND
Submission of medical records documenting a history of failure, contraindication, or intolerance to Ruconest (C1 esterase inhibitor [recombinant])
AND
Prescribed by an Immunologist or Allergist

Documentation of positive clinical response to Berinert therapy
AND
Prescribed for the acute treatment of HAE attacks
AND
Not used in combination with other products indicated for the acute treatment of HAE attacks (e.g., Firazyr, Ruconest)
AND
Prescribed by an Immunologist or Allergist

12 months