By Counterforce Health Team in Firazyr (icatibant injection) —

How to Get Firazyr (icatibant injection) Covered by Aetna (CVS Health) in Georgia: Complete Prior Authorization Guide

Answer Box: Getting Firazyr Covered by Aetna (CVS Health) in Georgia

Fastest Path to Approval: 1) Have an HAE specialist complete Aetna's Firazyr/icatibant precertification form with confirmed HAE diagnosis and attack history. 2) Submit through CVS Specialty Pharmacy (1-800-237-2767) for processing. 3) If denied, file internal appeal within 180 days with detailed medical necessity letter. First Step Today: Contact your HAE specialist to initiate the precertification request and verify your plan's formulary status.

Table of Contents

Plan Types & Network Requirements

Aetna offers HMO, PPO, and EPO plans in Georgia, each with different requirements for accessing Firazyr (icatibant injection):

HMO Plans

  • Require a primary care physician (PCP) and referrals to specialists
  • In-network only coverage (except emergencies)
  • Must use Aetna-contracted HAE specialists for prescriptions

EPO Plans

  • No PCP or referral requirements
  • In-network only coverage
  • Direct access to in-network allergists/immunologists

PPO Plans

  • No PCP or referral requirements
  • Both in-network and out-of-network coverage available
  • Higher costs for out-of-network providers
Note: Regardless of plan type, Firazyr requires prior authorization and must be dispensed through CVS Specialty Pharmacy for coverage.

Formulary Status & Coverage

Coverage at a Glance

Requirement Details Where to Find Source
Prior Authorization Required for all plans Member portal or formulary Aetna Policy CPB 0782
Formulary Tier Specialty Tier I (with generic icatibant) 2024 ACSF Specialty Drug List Aetna Specialty List
Step Therapy Not required by medical policy Clinical Policy Bulletin Aetna HAE Policy
Quantity Limits 45 syringes per 90 days Specialty quantity limits Aetna Quantity Limits

Important: Some Advanced Control formularies exclude Firazyr in favor of generic icatibant. Check your specific plan's exclusion list to confirm coverage.

Prior Authorization Requirements

Medical Necessity Criteria

Aetna requires the following for Firazyr approval:

  1. Specialist Involvement: Prescribed by or in consultation with an HAE specialist (allergist/immunologist)
  2. Confirmed HAE Diagnosis: Type I, II, or normal C1-INH HAE with genetic testing if applicable
  3. Acute Treatment Only: Not for prophylaxis or experimental uses
  4. No Combination Therapy: Cannot be used with other acute HAE treatments simultaneously

Required Documentation

For Initial Approval:

  • Completed Aetna precertification form
  • HAE diagnosis confirmation (C1-INH levels, genetic testing results)
  • Attack history and frequency documentation
  • Specialist consultation notes

For Renewals:

  • Evidence of clinical benefit (reduced attack severity/duration)
  • Updated attack logs
  • Continued specialist oversight

Quantity Limits & Dosing

Aetna's quantity limit for Firazyr is 45 syringes per 90 days, aligning with FDA-approved dosing:

  • Per Attack: Up to 3 doses (30 mg each) per 24-hour period
  • Dosing Interval: Minimum 6 hours between doses
  • Administration: Subcutaneous injection in abdomen over 30 seconds

This limit accommodates approximately 15 attacks per 90-day period, assuming maximum dosing per attack.

Quantity Limit Appeals

If you need more than 45 syringes per 90 days due to frequent attacks:

  1. Have your HAE specialist document attack frequency exceeding the limit
  2. Provide detailed attack logs with dates, severity, and response to treatment
  3. Include rationale for why additional syringes are medically necessary
  4. Submit appeal with supporting clinical documentation

Specialty Pharmacy Requirements

CVS Specialty Enrollment Process

Firazyr must be dispensed through CVS Specialty Pharmacy. Here's how to get started:

Step 1: Provider Enrollment

  • Complete the CVS HAE Enrollment Form
  • Include prescription details, patient information, and insurance data
  • Specify if self-injection training is needed

Step 2: Submission

Step 3: Patient Onboarding

  • CVS contacts patient for consent and shipping arrangements
  • Self-injection training coordinated if requested by prescriber
  • Ongoing clinical support and refill management
From Our Advocates: Many patients find success by having their HAE specialist's office coordinate directly with CVS Specialty during the initial enrollment. This streamlines the prior authorization process and ensures all required documentation is submitted together, often reducing approval time from weeks to days.

Appeals Process in Georgia

Level 1: Internal Appeal

Timeline: File within 180 days of denial; decision within 30 days

How to File:

  • Aetna member portal online
  • Mail to address on denial letter
  • Phone: 1-866-752-7021

Required Documents:

  • Original denial letter
  • Medical necessity letter from HAE specialist
  • Attack history and treatment response logs
  • Lab results confirming HAE diagnosis
  • Self-administration training documentation

Level 2: External Review (Georgia)

If your internal appeal is denied, you have the right to external review through the Georgia Department of Insurance.

Timeline: Request within 60 days of final internal denial Cost: Free to consumers Process: Independent physicians review your case

How to Request:

  • Contact Georgia DOI Consumer Services: 1-800-656-2298
  • Submit external review application
  • Provide all documentation from internal appeal

Expedited Review: Available for urgent medical situations (typically 72 hours)

For detailed guidance on Georgia's external review process, visit the Georgia Office of Commissioner of Insurance website.

Cost-Share Considerations

Typical Cost Structure

  • Deductible: May apply before coverage begins
  • Specialty Tier Copay/Coinsurance: Varies by plan design
  • Out-of-Pocket Maximum: Annual limit on your costs

Savings Options

Takeda Patient Support (OnePath)

  • Copay assistance for commercially insured patients
  • Bridge programs for coverage gaps
  • Enroll at Firazyr OnePath

Foundation Grants

  • Patient Advocate Foundation
  • HealthWell Foundation
  • National Organization for Rare Disorders (NORD)

Common Denial Reasons & Solutions

Denial Reason Solution
No HAE diagnosis Submit C1-INH lab results and genetic testing
Prophylactic use request Clarify prescription is for acute attacks only
Exceeding quantity limits Appeal with attack frequency documentation
Lack of specialist involvement Obtain consultation from board-certified allergist/immunologist
Missing self-administration training Complete training through CVS Specialty or specialist office

Medical Necessity Letter Checklist

Your HAE specialist should include:

  • Confirmed HAE diagnosis with subtype
  • Attack frequency, severity, and impact on quality of life
  • Prior treatments tried and outcomes
  • Clinical rationale for Firazyr specifically
  • Dosing plan and monitoring approach
  • References to HAE treatment guidelines or FDA labeling

When to Escalate

Contact these resources if standard appeals don't resolve your denial:

Georgia Department of Insurance

  • Consumer Services: 1-800-656-2298
  • File complaints about claim handling
  • Request external review assistance

Counterforce Health At Counterforce Health, we specialize in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical documentation to create targeted, evidence-backed rebuttals. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeal processes, particularly for specialty medications like Firazyr where detailed clinical justification is essential for approval.

Legal Assistance

  • Georgia Legal Services Program
  • Georgians for a Healthy Future (consumer advocacy)

FAQ

How long does Aetna prior authorization take in Georgia? Standard decisions are typically made within 30-45 days. Expedited reviews for urgent situations can be completed within 72 hours.

What if Firazyr is excluded from my formulary? You can request a formulary exception with clinical justification. Generic icatibant may be preferred on some plans.

Can I request an expedited appeal? Yes, if your medical situation is urgent. Contact your prescriber and Aetna immediately to request expedited review.

Does step therapy apply to Firazyr? Aetna's medical policy doesn't require trying other HAE medications first, but some formularies may have step therapy requirements. Check your specific plan documents.

What happens if I'm denied after external review? External review decisions are binding on the insurer. If approved, Aetna must cover the treatment. If denied, you may need to explore other legal options.

How do I verify my plan's coverage? Log into your Aetna member portal and search the formulary, or call member services at the number on your ID card.

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice. Always consult with your healthcare provider about treatment decisions and work with qualified professionals for insurance appeals. For official guidance on Georgia insurance regulations, contact the Georgia Department of Insurance.

Sources & Further Reading:

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