Medical Policy Updates

Notification of Policy Revisions Effective October 1, 2012 (Posted June 29, 2012 - Re-posted August 7, 2012)

Medical Policy	Revision
Treatment of Hereditary Angioedema "Notification"	New policy developed to address the FDA approved products used as treatment of Hereditary Angioedema. BCBSNC will provide coverage for Cinryze^®, Berinert^®, Kalbitor^® (Ecallantide), and Firazyr^® (Icatibant) when it is determined to be medically necessary because the medical criteria and guidelines are met. Medical Director review 6/2012. Notification given 6/29/12 for effective date 10/01/12. Laryngeal Hereditary Angioedema added as a clinical indication for treatment with Berinert^®. Policy remains on 90 day notification with effective date 10/01/2012.

Medical Policy

Revision

Treatment of Hereditary Angioedema "Notification"

New policy developed to address the FDA approved products used as treatment of Hereditary Angioedema. BCBSNC will provide coverage for Cinryze^®, Berinert^®, Kalbitor^® (Ecallantide), and Firazyr^® (Icatibant) when it is determined to be medically necessary because the medical criteria and guidelines are met. Medical Director review 6/2012. Notification given 6/29/12 for effective date 10/01/12. Laryngeal Hereditary Angioedema added as a clinical indication for treatment with Berinert^®. Policy remains on 90 day notification with effective date 10/01/2012.