Firazyr (icatibant subcutaneous injection − Takeda, generic) — Cigna

Initial criteria

• Patient has HAE type I or type II as confirmed by the following diagnostic criteria: (a) Patient has low levels of functional C1-INH protein (< 50% of normal) at baseline, as defined by the laboratory reference values [documentation required]; AND (b) Patient has lower than normal serum C4 levels at baseline, as defined by the laboratory reference values [documentation required]; AND
• The medication is prescribed by or in consultation with an allergist/immunologist or a physician who specializes in the treatment of HAE or related disorders

Reauthorization criteria

• Patient has a diagnosis of HAE type I or type II [documentation required]; AND
• According to the prescriber, the patient has had a favorable clinical response with icatibant treatment (e.g., decrease in duration of HAE attacks, quick onset of symptom relief, complete resolution of symptoms, or decrease in HAE acute attack frequency or severity); AND
• The medication is prescribed by or in consultation with an allergist/immunologist or a physician who specializes in the treatment of HAE or related disorders

Approval duration

1 year