MedicaidPrior AuthMedium impact
Ruconest (C1 esterase inhibitor, recombinant) (New)
Humana·IN · Allergy & Immunology, Internal Medicine, Pharmacy·Medicaid
Effective date
Oct 1, 2025
We identified it
Jul 23, 2026
Summary
Humana Indiana Medicaid has established a new Prior Authorization policy for Ruconest (C1 esterase inhibitor, recombinant) effective October 1, 2025. All claims for Ruconest must now meet 7 specific clinical criteria including HAE diagnosis confirmation, required laboratory documentation (C4, C1INH levels, C1q level), specialist treatment requirement, and documented recurrent angioedema history. This is a new coverage policy requiring immediate prior authorization submission before dispensing.
Action Required
By September 15, 2025: Billing and clinical teams must implement Ruconest prior authorization workflow for Indiana Medicaid members. (1) Update billing system to flag all Ruconest claims as requiring prior authorization before submission. (2) Create PA request template requiring documentation of: HAE Type 1 or 2 diagnosis, C4 level, C1INH antigenic OR functional level OR C1INH mutation documentation, C1q level, history of recurrent angioedema without urticaria, verification of specialist treatment (allergist/immunologist), and ruling out ACE inhibitor/ARB use and other angioedema causes. (3) Ensure pharmacy submits PA requests before dispensing; claims without prior authorization will be denied. (4) Train providers to document all 7 criteria in medical records to support PA approval. (5) Verify member's Indiana Medicaid coverage before processing claims. Contact Humana for PA submission portal access at www.humana.com/PAL.