CurrentCareSourcePolicy N/A

UTILIZATION MANAGEMENT MEDICAL POLICY

Defines prior authorization and medical necessity criteria for medical-benefit coverage of icatibant (subcutaneous injection) for treatment of acute HAE attacks in adults, including initial and continuation criteria, dosing limits, and exclusions (prophylaxis and non-listed indications).

Policy Summary

PayerCareSource

PolicyUTILIZATION MANAGEMENT MEDICAL POLICY

Policy CodePolicy N/A

Change TypeRevised (clarification and administrative wording)

Effective DateOct 9, 2024

Next Review Date

Key ActionPrior Authorization is recommended; approval requires meeting the stated criteria and dosing and prescribing by or in consultation with an allergist/immunologist or specialist.

SourceLink

POLICY UPDATE CHANGES

Added that a person who previously met initial therapy criteria under the Coverage Review Department and has treated previous HAE attacks with icatibant is only required to meet continuation criteria; if prior Coverage Review Department criteria were not met, initial criteria must be met.

Deleted '[Type I or Type II]' from indication heading for HAE due to C1-INH deficiency.

1Covered Indication (acute HAE attacks)

1Not Recommended Indication (prophylaxis)

30 mgMax per injection