- Hereditary Angioedema (HAE):
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Allergist;Immunologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Diagnosis Type(s): Prophylaxis against Acute HAE Attacks
HAE Type: 1 of HAE I;HAE II
Documented Lab Values: 1 of Low C1-INH Antigenic Level;Low C1-INH Functional Level;Normal C1-INH level;Positive F12 gene mutation to confirm Type III HAE
History of Moderate or Severe Attacks: No
- Prior Authorization: Hereditary Angioedema (HAE):
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
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