Sajazir — United Healthcare

acute attacks of hereditary angioedema (HAE)

Initial criteria

Diagnosis of hereditary angioedema (HAE) confirmed by ONE of the following:
EITHER C1 inhibitor (C1-INH) deficiency or dysfunction (Type I or II HAE) documented by ONE of:
• C1-INH antigenic level below the lower limit of normal
• C1-INH functional level below the lower limit of normal
OR HAE with normal C1 inhibitor levels AND ONE of:
• 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 refractory to high-dose antihistamines with confirmed family history of angioedema
• Recurring angioedema attacks refractory to high-dose antihistamines with unknown background de-novo mutation(s) (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., Berinert, Kalbitor, or Ruconest)
AND Prescribed by an Immunologist OR Allergist
Age ≥ 18 years

Documentation of positive clinical response to icatibant 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., Berinert, Kalbitor, or Ruconest)
AND Prescribed by an Immunologist OR Allergist

12 months