- Hereditary Angioedema (HAE):
Age Requirement: >= 12
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Allergist;Hematologist;Immunologist
Reauthorization Required: Yes
Duration of Reauthorization: <= 6 month(s)
Diagnosis Type(s): Treatment of Acute HAE Attacks
HAE Type: Unspecified
Documented Lab Values: 2 of Low C1-INH Antigenic Level;Low C1-INH Functional Level;Low C4 Level;Normal C1-INH level;Normal C4 level
History of Moderate or Severe Attacks: No
- Prior Authorization: Hereditary Angioedema (HAE):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 12
Duration: 6 Month(s)
Reauthorization Required: Yes
- Step Therapy: Hereditary Angioedema (HAE):
ST Single Generic
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