The following clinical criteria will be effective August 1, 2019.

 

Agents for Hereditary Angioedema ING-CC-0034

 

Effective for dates of service on and after August 1, 2019, the following specialty pharmacy codes from new or current clinical criteria will be included in our existing specialty pharmacy medical step therapy review process. Haegarda® and Takhzyro™ will be the preferred prophylactic agents over Cinryze®.

 

Please note, inclusion of NDC code on your claim will shorten the claim processing time of drugs billed with a Not Otherwise Classified (NOC) code.

 

You can go online to access the Clinical Criteria information.

 

Clinical Criteria

Status

Drug

HCPCS or CPT Code

NDC Code

ING-CC-0034

Preferred Agent

Haegarda®

J0599

63833-0828-02

63833-0829-02

ING-CC-0034

Preferred Agent

Takhzyro™

J3490, J3590, C9399

47783-0644-01

ING-CC-0034

Non-Preferred Agent

Cinryze®

J0598

42227-0081-05


* Notice of Prior Authorization or Material Adverse Change



Featured In:
May 2019 Anthem Provider Newsletter - Wisconsin