Firazyr — Medica
acute hereditary angioedema (HAE) attacks
Preferred products
- generic icatibant
Initial criteria
- Patient meets the standard Hereditary Angioedema – Icatibant (Firazyr) Prior Authorization Policy criteria
- Patient has tried generic icatibant [documentation required]
- The Brand product is being requested due to a formulation difference in the inactive ingredient(s) between the Brand and the bioequivalent generic product which, per the prescriber, would result in a significant allergy or serious adverse reaction [documentation required]
Approval duration
1 year