Icatibant (Firazyr)

Firazyr (icatibant) is covered only for treatment of acute hereditary angioedema (HAE) attacks in adults ≥18 and is not covered for off‑label uses or for use in combination with other acute HAE agents (e.g., Berinert, Kalbitor, Ruconest). Coverage requires documented laboratory confirmation of HAE (low C4 and abnormal C1 inhibitor antigenic and/or functional levels), documentation that the request is for an acute attack, proof of age ≥18, and adherence to the policy's safety and coverage criteria.

"Clinical records sufficient to demonstrate that the request meets the policy's coverage guidelines and applicable safety criteria for the covered indication."

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