Payer PolicyActive
C1 Esterase Inhibitor (Ruconest)
EVICORE-MEDICAL_DRUG-1EF6CCA6
EviCore by Evernorth
Effective: March 1, 2023
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Ruconest is covered only for the FDA‑approved use — treatment of acute attacks of hereditary angioedema (HAE) due to C1‑INH deficiency (type I or II); other indications are excluded. Initial (and 12‑month) authorization requires baseline labs showing functional C1‑INH <50% and low serum C4, prescription by or consultation with an allergist/immunologist or HAE specialist, weight‑based dosing (50 IU/kg IV, max 4,200 IU, ≤2 doses/day), and reauthorization requires prior Ruconest use with documented favorable clinical response.
Coverage Criteria Preview
Key requirements from the full policy
"Ruconest is indicated for the treatment of acute attacks of Hereditary Angioedema (HAE)."
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