By Counterforce Health Team in Firazyr (icatibant injection) —

How to Get Firazyr (Icatibant) Covered by Aetna CVS Health in Virginia: Complete Prior Authorization Guide

Answer Box: Getting Firazyr Covered by Aetna CVS Health in Virginia

Fastest path to approval: Submit the Aetna Firazyr-Sajazir Precertification Request form with confirmed HAE diagnosis (ICD-10: D84.1), specialist documentation, and attack logs. Standard decision: 30-45 days. If denied, Virginia residents can file external review within 120 days through the State Corporation Commission, which provides free, binding decisions within 45 days. Start today: Verify your plan covers specialty drugs and gather HAE diagnostic records from your specialist.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Plan Verification
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Tracking
  6. Typical Timelines in Virginia
  7. Common Denial Reasons and Solutions
  8. Virginia Appeals Process
  9. Renewal and Reauthorization
  10. Quick Reference Checklist
  11. FAQ

What This Guide Covers

This comprehensive guide helps Virginia residents with Aetna CVS Health insurance navigate the prior authorization process for Firazyr (icatibant injection), a critical medication for treating acute hereditary angioedema (HAE) attacks. Whether you're a patient, caregiver, or healthcare provider, you'll find step-by-step instructions, required forms, timelines, and appeal strategies specific to Virginia's regulatory environment.

Firazyr is a bradykinin B2-receptor antagonist that costs approximately $11,147 per 30 mg syringe. Given this significant expense, Aetna requires thorough documentation of medical necessity and adherence to specific approval criteria.

Before You Start: Plan Verification

Confirm Your Coverage Details

1. Verify Plan Type

  • Check if you have commercial Aetna, Aetna Better Health (Medicaid), or Medicare Advantage
  • Self-funded employer plans may have different requirements

2. Pharmacy vs. Medical Benefit

  • Firazyr is typically covered under the pharmacy benefit when dispensed by specialty pharmacy
  • May fall under medical benefit if administered in a healthcare facility
  • Contact Aetna member services at 1-800-872-3862 to confirm

3. Formulary Status

  • Firazyr requires prior authorization on most Aetna plans
  • Check your plan's specialty drug list or formulary
  • Generic icatibant may have different coverage requirements

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required for all HAE indications Aetna Precert List
Diagnosis Code ICD-10: D84.1 (Hereditary Angioedema) Medical records
Specialty Pharmacy CVS Caremark Specialty typically required Aetna member portal
Self-Administration Training Healthcare professional documentation required Provider notes
Quantity Limits Usually 2 syringes per month maximum Plan documents

Gather Required Documentation

Essential Clinical Documentation

HAE Diagnosis Confirmation:

  • Confirmed diagnosis with ICD-10 code D84.1
  • Laboratory results showing low C4 and C1-INH levels
  • Documentation from HAE specialist (immunologist, allergist, or hematologist)

Treatment History:

  • Detailed attack frequency and severity over past 12 months
  • Prior therapy trials and outcomes (including failures or intolerances)
  • Emergency department visits or hospitalizations due to HAE attacks
  • Current medications and prophylactic treatments (if any)

Self-Administration Requirements:

  • Documentation of completed self-injection training by healthcare professional
  • Patient education materials and competency verification
  • Emergency action plan for severe attacks
Tip: Keep a detailed HAE attack diary with dates, locations (face, throat, extremities), severity, and treatment response. This documentation significantly strengthens your prior authorization request.

Submit Your Prior Authorization Request

Step-by-Step Submission Process

1. Complete the Aetna Form Download and complete the Aetna Firazyr-Sajazir Injection Medication Precertification Request form. Ensure all sections are legible and complete—incomplete forms delay processing.

2. Gather Supporting Documents

  • Letter of medical necessity from HAE specialist
  • Recent laboratory results (C4, C1-INH levels)
  • Attack logs/diary covering past 12 months
  • Documentation of self-administration training
  • Previous prior authorization approvals (if renewing)

3. Submit Your Request

  • Online: Aetna provider web portal (fastest method)
  • Fax: 1-888-267-3277
  • Keep copies of all submitted materials and note submission date

4. Request Specialty Pharmacy Coordination If approved, Aetna will typically route to CVS Caremark Specialty for dispensing and ongoing support.

Clinician Corner: Medical Necessity Letter

Your HAE specialist should include these key elements in the medical necessity letter:

  • Problem Statement: Clear HAE diagnosis with attack frequency/severity
  • Prior Treatments: Specific therapies tried, outcomes, and reasons for discontinuation
  • Clinical Rationale: Why Firazyr is medically necessary for this patient
  • Dosing Justification: Requested quantity based on attack patterns
  • Monitoring Plan: Follow-up schedule and response measurement

Reference the FDA-approved labeling for acute HAE treatment and emphasize the rapid-acting nature needed for emergency self-treatment.

Follow-Up and Tracking

Monitoring Your Request

Timeline Expectations:

  • Standard decisions: 30-45 days from complete submission
  • Expedited reviews: 72 hours for urgent medical situations
  • Incomplete submissions may extend timelines

Follow-Up Script for Calling Aetna: "Hi, I'm calling to check the status of a prior authorization request for Firazyr submitted on [date]. The member ID is [number] and the reference number is [if available]. Can you tell me the current status and if any additional information is needed?"

Document Everything:

  • Call dates and representative names
  • Reference numbers provided
  • Any additional information requested
  • Promised callback dates

Typical Timelines in Virginia

Standard Processing Times

Review Type Aetna Timeline Virginia Regulation
Standard PA 30-45 days Must be reasonable
Expedited PA 72 hours For urgent situations
Internal Appeal 30 days State oversight applies
External Review 45 days Virginia SCC mandated
Expedited External 72 hours For urgent cases

Virginia's State Corporation Commission Bureau of Insurance provides oversight to ensure reasonable processing times. If Aetna exceeds standard timeframes without justification, you can file a complaint with the Bureau.

Common Denial Reasons and Solutions

Denial Reason How to Overturn
"No HAE diagnosis documented" Submit lab results, specialist notes with ICD-10 D84.1
"Requesting prophylactic use" Clarify on-demand use for acute attacks only
"Exceeds quantity limits" Provide attack diary showing frequency justification
"Lack of self-administration training" Submit training documentation from healthcare provider
"Alternative therapies not tried" Document contraindications or failures of C1-INH concentrates
"Not medically necessary" Strengthen specialist letter with attack severity/frequency

From Our Advocates

"We've seen many HAE patients succeed by keeping detailed attack diaries that clearly show the unpredictable nature of their condition. One patient's comprehensive documentation of nighttime attacks helped overturn a denial where the insurer initially questioned the need for at-home emergency treatment. While outcomes vary, thorough documentation consistently strengthens cases."

Virginia Appeals Process

Internal Appeals with Aetna

First-Level Appeal:

  • File within 180 days of denial
  • Submit via Aetna member portal or mail
  • Include additional clinical documentation
  • Decision within 30 days

Peer-to-Peer Review: Request a clinical discussion between your HAE specialist and Aetna's medical director. This often resolves complex cases before formal appeals.

Virginia External Review

Virginia provides one of the most patient-friendly external review processes in the nation. Here's how it works:

Eligibility:

  • Complete Aetna's internal appeals first
  • Denial must be based on medical necessity or experimental/investigational determination
  • Must be Virginia-issued plan or opted-in self-funded plan

How to File:

  1. Download Form 216-A (External Review Request) from Virginia SCC
  2. Submit within 120 days of final Aetna denial
  3. Include all denial letters and medical records
  4. No cost to you - Virginia provides free external review

Process:

  • Virginia SCC assigns to independent review organization (IRO)
  • Board-certified physicians review all evidence
  • Standard review: 45 days
  • Expedited review: 72 hours (if delay risks health)
  • Decision is binding on Aetna

Contact Information: Virginia State Corporation Commission
Bureau of Insurance Consumer Services
Phone: 1-877-310-6560
Website: scc.virginia.gov

Note: Virginia allows expedited external review for certain conditions without exhausting internal appeals first. Consult with the Bureau of Insurance to determine if your case qualifies.

Renewal and Reauthorization

Planning Ahead

Timeline for Renewals:

  • Start renewal process 60-90 days before expiration
  • Higher attack frequency may require earlier initiation
  • Keep updated attack logs and specialist notes

Required Documentation for Renewal:

  • Evidence of ongoing benefit (reduced attack severity/duration)
  • Current attack frequency data
  • Updated specialist evaluation
  • Confirmation of continued self-administration competency
  • Any changes in HAE management plan

Counterforce Health specializes in helping patients navigate complex prior authorization renewals by turning insurance requirements into targeted, evidence-backed submissions. Their platform can help identify exactly what documentation Aetna needs for your specific renewal situation.

Quick Reference Checklist

Before Submitting:

  • Confirmed HAE diagnosis (ICD-10: D84.1) documented
  • HAE specialist letter of medical necessity
  • Attack diary covering past 12 months
  • Self-administration training documentation
  • Prior therapy trials and outcomes documented
  • Current lab results (C4, C1-INH if available)
  • Aetna precertification form completed and legible

After Submission:

  • Reference number documented
  • Follow-up scheduled in 2 weeks
  • Specialty pharmacy coordination confirmed if approved
  • Appeal timeline noted if denied
  • Virginia external review option explained to patient

FAQ

How long does Aetna prior authorization take in Virginia? Standard decisions take 30-45 days. Expedited reviews for urgent medical situations are completed within 72 hours. Virginia regulations ensure reasonable processing times.

What if Firazyr is not on my formulary? You can request a formulary exception with documentation of medical necessity. If denied, Virginia's external review process can provide an independent evaluation.

Can I request an expedited appeal? Yes, if your HAE specialist certifies that waiting could seriously jeopardize your health. Virginia allows expedited external review within 72 hours for urgent cases.

Does step therapy apply to Firazyr? Some plans may require trying C1-INH concentrates first. Document any contraindications or failures with alternative treatments in your prior authorization request.

What happens if I need more than 2 syringes per month? Provide detailed attack frequency documentation to justify higher quantities. Many denials for quantity limits are overturned with proper clinical justification.

How does Virginia's external review compare to other states? Virginia offers free external review with binding decisions on insurers, faster timelines than federal requirements, and specialized oversight through the State Corporation Commission.

Can generic icatibant be substituted? Generic icatibant injection is available and may have different coverage requirements. Check with your specialty pharmacy about formulary status and cost differences.

What if my employer plan is self-funded? Many Virginia-headquartered self-funded plans opt into the state external review process. If not, you may have federal external review rights through HHS.

Sources & Further Reading

Disclaimer: This guide provides educational information about insurance processes and is not medical advice. Always consult with your healthcare provider about treatment decisions. Insurance coverage varies by plan, and policies change regularly. Verify current requirements with your insurer and refer to official Virginia state resources for the most up-to-date appeal procedures. For expert assistance with prior authorization appeals, Counterforce Health helps patients and clinicians turn insurance denials into successful, evidence-backed approvals.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.