Back to dashboard
Medicare AdvantagePrior AuthMedium impact

Cinryze (C1 esterase inhibitor, human) (Revised)

Humana·KY, SC · Allergy & Immunology, Pharmacy·Medicaid
Effective date
Jan 1, 2025
We identified it
Jul 21, 2026
Days to comply
—

Summary

This is a revised Humana prior authorization policy for Cinryze (C1 esterase inhibitor) covering HAE prophylaxis in Medicare and Medicaid (Kentucky and South Carolina) members. The policy establishes 8 approval criteria including HAE Type 1/2 diagnosis confirmation, specific lab documentation (C4, C1INH levels, C1q level), history of recurrent angioedema, specialist treatment requirement, and—critically for Medicaid—NO step therapy requirement (meaning prior trial of Haegarda is NOT required for Medicaid requests, though it IS required for Medicare Part B).

Action Required

Action needed
By January 1, 2025: Billing and prior authorization teams must implement the following for Cinryze requests in Kentucky and South Carolina Medicaid programs: (1) Create/update prior auth submission templates to require documentation of HAE Type 1 or Type 2 diagnosis with supporting lab values (C4 level, C1INH antigenic OR functional level OR C1INH mutation, AND C1q level per policy Criteria #6); (2) Require confirmation that member is under care of an allergist and/or immunologist; (3) Require documentation of recurrent angioedema history without concomitant urticaria; (4) Require medication history ruling out ACEIs, ARBs, and other angioedema-causing drugs; (5) FOR MEDICAID ONLY: Remove step therapy requirement—do NOT require prior Haegarda trial documentation (this differs from Medicare Part B which DOES require step therapy unless continuation of prior therapy within 365 days); (6) FOR MEDICARE PART B: Require step therapy documentation (Haegarda trial results, contraindication, or intolerance details) UNLESS request is continuation within past 365 days; (7) Update billing system denial logic to flag missing lab documentation (specifically C1q level) as a reason for request incompleteness. Failure to implement Medicaid step therapy exemption will cause unnecessary request denials and delays for eligible Medicaid members.

Related policy hubs