Coverage is provided in the following conditions:
• Patient is at least 13 years of age; AND
Universal Criteria
• Must be prescribed by, or in consultation with, a specialist in: allergy, immunology, hematology, pulmonology, or medical genetics; AND
• Patient does not have a history of allergy to rabbits or rabbit-derived products; AND
• Confirmation the patient is avoiding the following possible triggers for HAE attacks:
o Estrogen-containing oral contraceptive agents AND hormone replacement therapy; AND
o Antihypertensive agents containing ACE inhibitors; AND
o Dipeptidyl peptidase IV (DPP-IV) inhibitors (e.g., sitagliptin); AND
o Neprilysin inhibitors (e.g., sacubitril); AND
Treatment of acute abdominal, peripheral, or facial attacks of Hereditary Angioedema (HAE)
Patient has a history of moderate to severe cutaneous attacks (without concomitant hives)OR abdominal attacks OR mild to severe airway swelling attacks of HAE (i.e. debilitating cutaneous/gastrointestinal symptoms OR laryngeal/pharyngeal/tongue swelling); AND
Patient has one of the following clinical presentations consistent with a HAE subtype§,which must be confirmed by repeat blood testing (treatment for acute attack should not bedelayed for confirmatory testing):
