Limited Coverage Drugs – Icatibant
Generic Name: |
icatibant |
|
---|---|---|
Strength: |
30 mg/3 mL |
|
Form: |
pre-filled syringe |
Special Authority Criteria |
Approval Period |
---|---|
Initial: For the treatment of acute attacks of hereditary angioedema (HAE) in adult patients with lab confirmed c1-esterase inhibitor deficiency (type I or type II) who meet ALL of the following criteria:
AND
AND
|
1 year1 |
Renewal:
AND
AND
|
1 year1 |
Practitioner Exemptions
- No practitioner exemptions.
Special Notes
- PharmaCare coverage is limited to a maximum of 24 pre-filled syringes per year.
- Non-laryngeal attack of at least moderate severity is defined as cutaneous swellings of the face and/or neck or abdominal attacks. Cutaneous swellings of areas other than the face or neck are not eligible for PharmaCare coverage.
- To minimize drug wastage, patients are limited to a maximum of one pre-filled syringe of icatibant dispensed per prescription fill. Patients should not fill an additional dose of icatibant prior to the utilization of the patient’s existing pre-filled syringe of the drug.
- Prophylaxis of HAE attacks is not eligible for PharmaCare coverage.