Berinert (C1 esterase inhibitor, human) (New)

Before October 1, 2025: Billing and clinical teams must implement prior authorization workflows for Berinert in the billing system for Humana Indiana Medicaid members. (1) Update billing software to flag all Berinert requests for prior authorization submission. (2) Create/update prior authorization templates to require: HAE Type 1 or 2 diagnosis confirmation, lab documentation (C4 level, C1INH antigenic OR functional level, C1q level, or C1INH mutation documentation), evidence of recurrent angioedema episodes without urticaria, confirmation of specialist care (allergist/immunologist), exclusion of confounding medications (ACEIs, ARBs) and alternative causes, and confirmation of acute attack treatment (abdominal, facial, or laryngeal). (3) Train pharmacy and authorization staff on the seven approval criteria listed in the policy. (4) Distribute updated policy to all providers and pharmacies serving Indiana Medicaid patients. (5) Update encounter forms/pharmacy request forms to prompt collection of required lab values and specialist information before submission. Claims submitted without prior authorization or missing required documentation will be denied. Note: Policy revisions may occur; verify current version on Humana's website before each authorization.