Subject: Specialty Quantity Limit icatibant-Sajazir-Firazyr 3057-H P2024
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FIRAZYR
(icatibant)
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icatibant
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SAJAZIR ®
(icatibant)
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Policy:
I. PROGRAM DESCRIPTION
The standard limit is designed to allow a quantity sufficient for the most common uses of the medication. The recommended dosing parameters for all FDA-approved indications fall within the standard limits. Coverage of an additional quantity may be reviewed on a case-by-case basis upon request.
II. COVERED QUANTITIES
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Medication
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Standard Limit**
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FDA-recommended dosing
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Firazyr (icatibant) 30 mg/3 mL (10 mg/mL) prefilled syringe
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45 syringes per 90 days
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30 mg subcutaneously
Additional doses may be administered at intervals of at least 6
hours (up to 3 doses may be administered in any 24-hour period)
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Sajazir (icatibant) 30 mg/3 mL (10 mg/mL) prefilled syringe
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** The limit may apply to the generic equivalent medications.
Place of Service:
Outpatient
The above policy is based on the following references:
- Firazyr [package insert]. Lexington, MA: Takeda Pharmaceuticals America, Inc.; January 2024.
- icatibant [package insert]. Berkeley Heights, NJ: Hikma Pharmaceuticals; February 2024.
- Sajazir [package insert]. Cambridge, United Kingdom: Cycle Pharmaceuticals Ltd; May 2022.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
November 03, 2024
