Firazyr® and generic icatibant

Authorization form

Traditional & Optimized (09/2019)


*Only generic icatibant is formulary for Medicare.

Priority Health Medicare Part D no longer utilize drug-specific prior authorization forms for drugs covered under the pharmacy benefit.

Visit the Approved Drug List (ADL) to search by drug name and view the criteria and PA form.

Go to Medicare ADL

Code(s): J1744

Benefit: Pharmacy only

Notes: For treatment of acute attacks of hereditary angioedema.