Cinryze® (plasma-derived C1 esterase inhibitor)

Authorization forms 

Medicare Part B (05/2018)


Traditional & Optimized: Cinryze is not covered.

Medicaid: This is a carve-out. 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