By Counterforce Health Team in Firazyr (icatibant injection) —

Firazyr (icatibant injection) Approval with Aetna (CVS Health) in Florida: Complete Guide with Forms and Appeal Scripts

Quick Answer: Getting Firazyr Covered by Aetna in Florida

Yes, Firazyr (icatibant) is covered by Aetna CVS Health for acute HAE attacks in Florida members. The fastest path: 1) Have your HAE specialist submit prior authorization with confirmed C1-INH deficiency labs and self-administration training documentation, 2) Submit through CVS Caremark Specialty at 1-866-237-5512, 3) If denied, appeal within 180 days citing Florida's step therapy exemption rights. Start today by gathering your HAE diagnosis labs and attack history documentation.

Table of Contents

Coverage Basics

Is Firazyr (icatibant injection) covered by Aetna in Florida?

Firazyr appears on Aetna's 2025 Specialty Drug List and requires prior authorization for all Florida members. Coverage is limited to acute hereditary angioedema (HAE) attacks in adults with confirmed C1-INH deficiency.

Which Aetna Plans Cover Firazyr?

Plan Type Coverage Status Pharmacy Network
Commercial PPO/HMO Covered with PA CVS Specialty required
Aetna Better Health (Medicaid) Covered with PA CVS Specialty required
Medicare Part D Varies by plan Check plan formulary

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Gather Documentation (Patient/Clinic)
    • HAE diagnosis with C4 and C1-INH lab results
    • Attack history with dates and severity
    • Self-administration training completion certificate
    • Timeline: 1-2 days
  2. Complete PA Form (Prescriber)
  3. Submit to CVS Caremark (Prescriber)
    • Fax to: 1-866-237-5512
    • Or submit via Availity portal
    • Timeline: Same day
  4. Await Decision (Aetna)
    • Standard review: 30 days
    • Expedited review: 72 hours (if urgent)
  5. Enroll in CVS Specialty (Patient)
    • Call 1-800-237-2767 once approved
    • Arrange refrigerated home delivery
    • Timeline: 2-3 days

Clinician Corner: Medical Necessity Letter Checklist

When submitting your PA request, include:

Essential Elements:Confirmed HAE Type I or II diagnosis with lab valuesFrequency and severity of recent attacks (last 12 months)Prior therapy failures or contraindications to alternativesPatient's ability to self-administer (training documentation)Clinical rationale for Firazyr vs. other HAE treatmentsDosing plan aligned with FDA labeling

Timing and Urgency

How Long Does Aetna PA Take in Florida?

Review Type Timeline When to Use
Standard 30 days Routine refills
Expedited 72 hours Active HAE attacks or imminent risk
Emergency Same day Life-threatening situations

What If It's Urgent?

For active HAE attacks, request expedited review by:

  • Marking "URGENT" on PA form
  • Having prescriber call Aetna at 1-800-872-3862
  • Providing clinical justification for urgency

Medical Necessity Criteria

What Counts as Step Therapy for HAE?

Aetna's clinical policy typically requires documentation of:

  • Failed or contraindicated alternatives: C1-INH concentrates (Berinert, Ruconest) or ecallantide (Kalbitor)
  • Medical reasons for Firazyr preference: IV access issues, self-administration needs, prior efficacy

Required Lab Values

Test Requirement Source
C4 level Low (confirms complement consumption) Aetna policy
C1-INH level/function Low or dysfunctional Aetna policy
Attack frequency Documented episodes Clinical notes required

Quantity Limits

Standard approval: 2-3 syringes per month, corresponding to expected attack frequency. Higher quantities require additional justification with documented attack patterns.

Costs and Copay Assistance

Understanding Your Out-of-Pocket Costs

Firazyr is classified as a specialty drug, typically requiring:

  • Specialty tier copay or coinsurance (often 20-50%)
  • Deductible may apply depending on plan design

Savings Options

  1. Takeda Patient Support Program
    • May reduce copays for eligible patients
    • Apply at Firazyr.com
  2. CVS Caremark Specialty Copay Programs
    • Available for qualifying patients
    • Inquire when enrolling: 1-800-237-2767

Denials and Appeals

Common Denial Reasons & How to Fix Them

Denial Reason Solution Required Documentation
"No HAE diagnosis" Submit complete lab workup C4, C1-INH levels with reference ranges
"Step therapy required" Request exemption Prior failure/contraindication documentation
"Quantity exceeded" Justify attack frequency Attack diary with dates and severity
"Self-administration not documented" Submit training proof Completion certificate from provider

Appeals Playbook for Aetna in Florida

Level 1: Internal Appeal

  • Deadline: 180 days from denial
  • Submit to: Aetna provider portal or mail
  • Timeline: 30 days standard, 72 hours expedited
  • Required: Original denial letter, clinical documentation, appeal form

Level 2: External Review (Florida)

  • Deadline: 4 months after final internal denial
  • Submit to: Florida Department of Financial Services
  • Contact: 1-877-MY-FL-CFO (1-877-693-5236)
  • Cost: Free to consumers
  • Timeline: 45 days standard, 72 hours expedited
  • Decision: Binding if in patient's favor

Patient Phone Script for Aetna

"Hi, I'm calling about a prior authorization denial for Firazyr for hereditary angioedema. My member ID is [ID number]. I'd like to understand the specific reason for denial and start an internal appeal. Can you transfer me to the appeals department and provide the appeal form reference number?"

Renewals and Reauthorization

When to Reauthorize Firazyr

Most Aetna approvals are valid for 12 months. Submit renewal requests 30-60 days before expiration to avoid gaps in coverage.

What Changes Require New PA?

  • Dose increases beyond approved quantity
  • Change in prescribing physician
  • New insurance plan year (may require resubmission)

CVS Specialty Pharmacy Enrollment

Required Steps for Florida Delivery

  1. Enrollment Call: 1-800-237-2767 after PA approval
  2. Verify Insurance: Confirm Aetna coverage and copay
  3. Delivery Setup: Schedule refrigerated home delivery
  4. Emergency Protocol: Discuss urgent refill procedures
Note: Firazyr requires refrigeration. Ensure someone is home for delivery or arrange secure refrigerated storage.

Troubleshooting Common Issues

Portal Problems

  • Availity down: Call Aetna provider line at 1-800-872-3862
  • Missing forms: Download from Aetna's form library

Communication Issues

  • No PA response: Follow up after 30 days (standard) or 72 hours (expedited)
  • Specialty pharmacy transfer: Contact CVS Specialty at 1-800-237-2767

Florida-Specific Rights

Step Therapy Exemption (HB 459)

Florida law allows you to bypass "fail first" requirements if:

  • You've been stable on Firazyr previously
  • Alternatives are contraindicated or caused adverse reactions
  • You've completed step therapy within the past 90 days

Continuity of Care Protection

If you were stable on Firazyr in the previous 90 days with continuous coverage, Aetna cannot force you to restart step therapy mid-year.

Consumer Assistance

Florida Department of Financial Services

  • Insurance Consumer Helpline: 1-877-MY-FL-CFO
  • Online complaint portal for insurance disputes
  • Free assistance with appeals and external reviews

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals for patients, clinicians, and specialty pharmacies. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that align with each payer's specific requirements, helping patients get the medications they need.

From Our Advocates: "We've seen Florida patients successfully appeal Firazyr denials by emphasizing the state's step therapy exemption rights and providing comprehensive attack documentation. The key is showing why IV alternatives aren't suitable and demonstrating proper self-administration training. Success rates improve significantly when appeals include specialist letters addressing specific denial reasons rather than generic medical necessity arguments."

Frequently Asked Questions

Q: How long does Aetna PA take for Firazyr in Florida?
A: Standard reviews take up to 30 days; expedited reviews for urgent HAE attacks are completed within 72 hours.

Q: What if Firazyr is non-formulary on my plan?
A: Request a formulary exception with clinical documentation showing medical necessity and prior therapy failures.

Q: Can I request an expedited appeal in Florida?
A: Yes, for urgent medical situations. Both internal appeals with Aetna and external reviews through Florida DFS offer expedited timelines.

Q: Does step therapy apply if I failed alternatives outside Florida?
A: Yes, document prior failures regardless of where they occurred. Florida's step therapy exemption law protects patients with documented contraindications.

Q: What happens if CVS Specialty can't deliver to my Florida address?
A: Contact CVS Specialty at 1-800-237-2767 to arrange alternative delivery or pickup locations that maintain refrigeration requirements.

Q: How do I prove self-administration training to Aetna?
A: Obtain a completion certificate from your prescribing physician or HAE specialist documenting successful training and competency demonstration.

Sources & Further Reading

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider regarding your specific medical condition and treatment options. Insurance coverage and policies may vary and change over time.

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