Firazyr® and generic icatibant
Authorization formTraditional & 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
Benefit: Pharmacy only
Notes: For treatment of acute attacks of hereditary angioedema.