CurrentCignaPolicy N/A

Icatibant (Firazyr/Sajazir) drug quantity limits for hereditary angioedema

Defines quantity limits and exception/override criteria for icatibant (Firazyr and Sajazir) used to treat acute hereditary angioedema attacks for Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyIcatibant (Firazyr/Sajazir) drug quantity limits for hereditary angioedema

Policy CodePolicy N/A

Change TypeRevised (quantity override increased)Clarified duration

Effective DateN/A

Next Review DateFeb 19, 2025

Key ActionApprove a one-time override of up to 12 additional prefilled syringes when additional doses are required for a subsequent HAE attack; calculate approval quantity as prior syringes received +12 (retail: past 28 days; home delivery: past 84 days).

SourceLink

POLICY UPDATE CHANGES

Override criteria were updated to approve a one-time override for 12 additional prefilled syringes (previously 3) when additional doses are required for a subsequent attack.

Policy statement updated to note that 'one-time' approvals are provided for 30 days in duration.

12Retail max / 28 days

36Home delivery max / 84 days

30 mgPer-dose strength

≤3Max doses / 24 hrs

Up to 12One-time override

Coverage Criteria

One-time override criteria

Approve when the following single condition is met

One-time override for additional doses: If the patient requires additional doses of icatibant to treat a subsequent attack of hereditary angioedema, approve a one-time override for the requested quantity, not to exceed 12 additional prefilled syringes at retail or home delivery.<=12 additional syringes

At retail, approval quantity = the number of prefilled syringes the patient received in the past 28 days plus 12; at home delivery, approval quantity = the number of prefilled syringes the patient received in the past 84 days plus 12. ONE override may be approved ONCE every 30 days.

Any exception beyond the stated Drug Quantity Limits and the one-time override is considered not medically necessary.

Requests that exceed the specified quantity limits and do not meet the one-time override criteria are considered not medically necessary.

Coding and Dosing Limits

Policy Summary

PayerCigna

PolicyIcatibant (Firazyr/Sajazir) drug quantity limits for hereditary angioedema

Policy CodePolicy N/A

Change TypeRevised (quantity override increased)Clarified duration

Effective DateN/A

Next Review DateFeb 19, 2025

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions and Billing Rules

Billing Rule

Drug quantity limits and one-time override

Drug Quantity Limits: Firazyr® (icatibant SC injection, generic) and Sajazir™ (icatibant SC injection) are subject to Drug Quantity Management limits. Retail maximum = 12 prefilled syringes per 28 days. Home delivery maximum = 36 prefilled syringes per 84 days. This supply assumes up to four acute hereditary angioedema attacks per 28 days (retail) or 12 attacks per 84 days (home delivery), with up to three doses per attack. Exceptions for additional doses are considered only under the criteria below.

Firazyr® / Sajazir™ package size: 30 mg/3 mL prefilled syringes
Retail limit: 12 syringes per 28 days
Home delivery limit: 36 syringes per 84 days
Quantity rationale: sufficient for 4 attacks (28 days) or 12 attacks (84 days) assuming up to 3 doses per attack

Prior Authorization

Provider action: follow Drug Quantity Management and criteria

If the Drug Quantity Management rule is not met at point of service, assess coverage per the policy criteria. Providers may request a one-time override when a patient requires additional doses for a subsequent hereditary angioedema attack. One-time overrides are time-limited (see override calculation) and may be approved only under the conditions in the criteria.

All approvals are provided for the duration noted in criteria
One-time approvals are provided for 30 days in duration
If quantity limits are exceeded at point of sale, coverage is determined by criteria and prior authorization rules

Note

Override quantity calculation and frequency

Calculation for override approval: at retail, approve a quantity equal to the number of prefilled syringes the patient received in the past 28 days plus up to 12 additional syringes. At home delivery, approve a quantity equal to the number of prefilled syringes the patient received in the past 84 days plus up to 12 additional syringes. A one-time override may be approved once every 30 days.

Retail approval quantity = syringes received in past 28 days + 12
Home delivery approval quantity = syringes received in past 84 days + 12
One-time override frequency: ONE override may be approved ONCE every 30 days
Maximum one-time override quantity: not to exceed 12 additional prefilled syringes

Denial Risk

Quantity limit denial risk

Denial risk: If the requested quantity exceeds the Drug Quantity Management limits and does not meet the one-time override criteria, the claim may be denied at point of service. Ensure documentation supports the need for additional doses and that any override request follows the calculation and timing rules described.

Point-of-service Drug Quantity Management rule applies
Requests exceeding limits without meeting criteria or lacking required documentation may be denied
Support override requests with clinical documentation of subsequent attack requiring additional doses

OpenPayer

Icatibant (Firazyr/Sajazir) drug quantity limits for hereditary angioedema

Coverage Criteria

Coding and Dosing Limits

Provider Actions and Billing Rules

Background

Definitions

Quantity Limits (per product and channel)