Cinryze® (plasma-derived C1 esterase inhibitor)

Authorization forms

Traditional & Optimized (09/2018)

Medicare Part B (05/2018)

 

This is a carve-out for Medicaid. Please contact Fee For Service Medicaid for coverage.

No prior authorization required for:

  • Emergency room
  • Inpatient
  • Skilled nursing facility

Injectable auth/billing notes:

Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.

Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.

Code(s): J0598

Benefit: Medical

Notes: Per 10 u; treatment of  C1 esterase inhibitor [C1-INH] deficiency