Cinryze (C1 esterase inhibitor, human) — United Healthcare

Prophylaxis of hereditary angioedema (HAE) attacks

Preferred products

Diagnosis of hereditary angioedema (HAE) confirmed by ONE of the following:
- C1-INH deficiency or dysfunction (Type I or II HAE) documented by ONE of the following:
• 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 gene(s) for factor XII, angiopoietin-1, plasminogen-1, kininogen-1, myoferlin, or heparan sulfate-glucosamine 3O-sulfotransferase 6 OR
• Recurring angioedema attacks refractory to high-dose antihistamines with confirmed family history of angioedema OR
• Recurring angioedema attacks refractory to high-dose antihistamines with unknown background (HAE-unknown)
AND Prescribed for the prophylaxis of HAE attacks
AND Not used in combination with other products indicated for prophylaxis against HAE attacks (e.g., Haegarda, Orladeyo, Takhzyro)
AND Prescriber attests patient has experienced attacks of a severity and/or frequency such that they would clinically benefit from prophylactic therapy with Cinryze
AND History of failure to BOTH of the following (document date of trial and reason for failure):
• Haegarda (C1 esterase inhibitor, human)
• Takhzyro (lanadelumab)
AND Prescribed by an Immunologist OR Allergist

Documentation of positive clinical response to Cinryze therapy
AND Reduction in utilization of on-demand therapies used for acute attacks (e.g., Berinert, Firazyr, Ruconest) as determined by claims information while on Cinryze
AND Prescribed for the prophylaxis of HAE attacks
AND Not used in combination with other products indicated for prophylaxis against HAE attacks (e.g., Haegarda, Orladeyo, Takhzyro)
AND Prescribed by an Immunologist OR Allergist

12 months