Summary
Effective 04/01/2026, the BCBSMS hereditary angioedema policy added Andembry (garadacimab-gxii), Dawnzera (donidalorsen), and Ekterly (sebetralstat) to its list of drugs, and Sajazir (icatibant) was added effective the same date. The revised criteria cover documentation of recurrent angioedema episodes and HAE subtype, and add separate criteria for acute attack treatment and for routine prophylaxis. Dawnzera and Ekterly are considered not medically necessary because other formulary alternatives are covered by the Plan for both acute and prophylactic treatment of HAE attacks.
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What to do
Action · 8 steps
01Already effective 04/01/2026: Billing team, perform a formulary drug search on the patient's member ID to confirm the drug is covered under their benefit plan.
02Prior authorization is required under this policy.
03Documentation must show one of the listed HAE criteria, such as C1-INH protein level, C1-INH function level, and C4 level measurements, a mutation in the C1-INH gene, or, for HAE-unknown, confirmation by an HAE specialist with medical records.
04Medications known to cause angioedema, such as ACE inhibitors, estrogens, angiotensin II receptor blockers, and NSAIDs, must have been evaluated and discontinued when appropriate.
05The prescriber must be a specialist or have consulted one, such as an allergist or immunologist.
06Samples used by the individual are not considered current or stable therapy.
07Andembry is limited to 200mg once monthly, and the initial approval length is 12 months.
08Services for delivery or administration of a medication that were not approved through the BCBSMS PA review are considered not medically necessary.
Codes mentioned
J0597J0599J1744J0593J0596J0598J1290D84.1
Original notice
Hereditary Angioedema (HAE)
bcbsms.com · Always check the source before changing claims.