Medicare AdvantagePrior AuthMedium impact
Andembry ® (garadacimab-gxii) (Revised)
Humana·SC · Allergy & Immunology, Pharmacy·Medicaid
Effective date
Jul 23, 2025
We identified it
Jul 21, 2026
Summary
This is a revised Humana prior authorization policy for Andembry (garadacimab-gxii) for HAE prophylaxis in Medicare and Medicaid-South Carolina. The policy establishes 8 coverage criteria including HAE Type 1/2 diagnosis confirmation via specific lab values (C4, C1INH antigenic/functional levels, C1q level), documentation of recurrent angioedema without urticaria, treatment by a specialist, and a step-therapy requirement for Medicaid patients (trial or documented contraindication/intolerance to Haegarda). This is a pharmacy coverage policy requiring prior authorization before dispensing.
Action Required
By July 23, 2025: Billing and Prior Authorization teams must implement this revised Andembry coverage policy in authorization systems. Specifically: (1) Configure prior auth system to require all 8 criteria for approval; (2) For Medicaid requesters, configure system to note that step-therapy requirements do NOT apply per policy statement; (3) For all requests, require submission of: HAE Type 1/2 diagnosis confirmation, lab report with C4 level, C1INH antigenic OR functional level OR C1INH mutation documentation, AND C1q level results; (4) Require documentation of recurrent angioedema attacks without urticaria; (5) Verify treating provider is allergist or immunologist; (6) For Medicare Advantage members, require documentation of prior Haegarda trial/response, contraindication, or intolerance; (7) Flag requests that do not meet all criteria for medical director review before denial. Update prior auth forms and intake templates. Failure to implement all criteria will result in incorrect approvals/denials and compliance issues.