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C-1 Esterase Inhibitor

Drug - Cinryze (C1 esterase inhibitor) [ViroPharma]
            Berinert (C1 esterase inhibitor) [CSL Behering]

June 2013

Therapeutic area - Hereditary Angioedema

Berinert criteria

Patient has a diagnosis of hereditary angioedema

Cinryze criteria 

  • Patient has been diagnosed with hereditary angioedema (HAE) AND
  • Patient is not taking an angiotensin converting enzyme (ACE) Inhibitor or estrogen replacement therapy AND
  • Patient has shown compliance with danazol 200 mg once or twice a day AND
  • Patient continues to demonstrate (must) a documented history of greater than 2 HAE attacks per month AND
  • Patient has tried and failed tranexamic acid AND
  • The department authorizes (must) long term prophylaxis use
  • Coverage for renewal of Cinryze therapy for routine prophylaxis requires documentation of response of at least 50 percent or greater reduction in attacks and or severity

Billing

Berinert must be reconstituted and infused, if the dose is to be administered at home, the Department will require some documentation that the patient has been taught self-infusion techniques. Berinert doses given at a health care center or facility must be billed on a professional claim using J0597 (buy-and-bill).

Cinryze must be reconstituted and infused; if the dose is to be administered at home, the Department will require documentation that the patient has been taught self-infusion techniques. Cinryze doses given at a health care center or facility must be billed on a professional claim using J0598 (buy-and-bill).

Questions?

MHCP Provider Call Center 651-431-2700 or 800-366-5411

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