By Counterforce Health Team in Firazyr (icatibant injection) —

Renewing Firazyr (Icatibant) Approval with Aetna CVS Health in Ohio: Complete Timeline & Forms Guide

Answer Box: Renewing Firazyr (Icatibant) with Aetna CVS Health in Ohio

Start your renewal 60-90 days before your current authorization expires. Aetna requires their Firazyr-Sajazir Injection Medication Precertification Request form with updated clinical documentation showing ongoing HAE attacks and treatment response. Submit via Aetna provider portal (3-5 business days) or fax to 1-888-267-3277. If denied, Ohio residents have 180 days for external review through the Ohio Department of Insurance.

Table of Contents

Renewal Triggers: When to Start

Don't wait until your Firazyr authorization expires. Here's when to begin your renewal process:

Start 60-90 Days Early If:

  • You've had 3+ HAE attacks requiring Firazyr in the past year
  • Your current authorization covers fewer syringes than you typically need
  • You're approaching your plan's annual renewal period (January 1st for most plans)
  • You've had prior denials or appeals with Aetna

Start 30-45 Days Early If:

  • Your HAE is well-controlled with predictable attack patterns
  • Previous renewals were approved without issues
  • All clinical documentation is current and accessible
Note: Aetna's precertification list confirms Firazyr requires ongoing authorization for both initial and renewal requests.

Evidence Update Requirements

Your renewal must demonstrate ongoing medical necessity with current clinical evidence:

Required Clinical Updates

  • Attack frequency and severity over the past 12 months
  • Treatment response data including time to symptom relief
  • Adherence documentation showing proper self-administration
  • Current C4 levels and C1-INH testing (if repeated annually per your specialist)
  • Any adverse events or medication complications

Documentation Your HAE Specialist Should Provide

  1. Updated treatment summary with attack patterns
  2. Confirmation of ongoing HAE diagnosis with ICD-10 code D84.1
  3. Evidence of proper self-administration training completion
  4. Justification for quantity requested based on historical usage
  5. Statement that alternative treatments remain inappropriate
Clinician Corner: Include specific attack dates, locations (face, throat, extremities), duration before and after Firazyr administration, and any emergency department visits avoided through self-treatment.

Renewal Documentation Packet

Aetna requires their specific Firazyr-Sajazir Precertification Request form for all renewals. The form includes a "continuation of therapy" section requiring:

Must-Include Documents

Document Purpose Source
Completed precertification form Official Aetna requirement Aetna form PDF
HAE specialist letter Medical necessity justification Your allergist/immunologist
Attack diary/log Usage patterns and response Patient records
Previous authorization approval Reference number and dates Aetna member portal
Current insurance card copy Plan verification Your wallet

Letter of Medical Necessity Structure

Your HAE specialist should address:

  1. Patient identification and confirmed HAE diagnosis
  2. Treatment history including date of last Firazyr administration
  3. Clinical response to current therapy
  4. Quantity justification based on attack frequency
  5. Contraindications to alternative HAE treatments
  6. References to FDA labeling and HAE guidelines

Submission Timeline & Decision Windows

Submission Options & Processing Times

Method Timeline Contact
Aetna provider portal 3-5 business days Fastest option
Fax submission 5-7 business days 1-888-267-3277
Urgent/expedited 24-72 hours 1-866-752-7021

Decision Timeline Expectations

  • Initial review: 5-10 business days after complete submission
  • Additional information requests: Add 3-5 days for provider response
  • Final determination: Typically within 15 business days total
  • Appeals process: 30 days for internal, 30 days for Ohio external review
Tip: Submit through the Aetna provider portal when possible. Electronic submissions receive priority processing and automatic confirmation receipts.

If Coverage Lapses: Bridge Options

If your Firazyr authorization expires before renewal approval, you have several emergency access options:

Immediate Actions

  1. Contact Takeda Patient Support at the number on Firazyr.com for emergency assistance programs
  2. Request expedited review from Aetna if you have pending attacks
  3. Consult your HAE specialist about hospital-based alternatives (Berinert, Ruconest)
  4. Document the lapse for potential retroactive coverage claims

Temporary Bridge Therapy

  • C1-INH concentrates available in emergency departments
  • Ecallantide (Kalbitor) for healthcare facility administration
  • Fresh frozen plasma as last resort in critical situations
Important: Never delay emergency care during coverage gaps. Ohio hospitals must provide stabilizing treatment regardless of insurance status.

Annual Plan Changes to Monitor

Aetna makes formulary changes that can affect Firazyr coverage:

Key Changes for 2025

  • Formulary exclusions: Firazyr remains excluded from Aetna's Advanced Control Plan
  • Quantity limits: May be adjusted based on utilization data
  • Prior authorization criteria: Updates to step therapy requirements
  • Specialty pharmacy requirements: CVS Specialty remains the preferred network

What to Verify Annually

  • Your plan's formulary status for Firazyr
  • Updated prior authorization requirements
  • Changes to quantity limits or dosing restrictions
  • New step therapy requirements
  • Specialty pharmacy network changes

Check Aetna's formulary updates each January and July for mid-year changes.

Appeals Process for Ohio Residents

If Aetna denies your Firazyr renewal, Ohio provides strong consumer protections:

Internal Appeals with Aetna

  1. File within 180 days of denial notice
  2. Submit additional clinical evidence supporting medical necessity
  3. Request peer-to-peer review between your HAE specialist and Aetna's medical director
  4. Expect decision within 30 days (72 hours for expedited)

Ohio External Review Process

If internal appeals fail, Ohio residents can request independent external review:

Step Timeline Action Required
Request external review Within 180 days of final Aetna denial Submit request to Ohio DOI
IRO assignment 5 business days Ohio DOI assigns Independent Review Organization
Medical review 30 days standard, 72 hours expedited IRO reviews all medical evidence
Final decision Binding on Aetna Coverage required if medically necessary
Ohio Advantage: The state has recovered over $21 million in previously denied benefits through external review. Contact Ohio DOI at 1-800-686-1526 for assistance.

Personal Renewal Tracker

Use this template to track your Firazyr renewal progress:

Key Dates

  • Current authorization expires: ___________
  • Renewal submission target: ___________
  • Expected decision date: ___________
  • Appeal deadline (if needed): ___________

Documentation Checklist

  • Completed Aetna precertification form
  • HAE specialist letter of medical necessity
  • Attack diary from past 12 months
  • Current lab results (if applicable)
  • Previous authorization reference number
  • Insurance card copy

Submission Tracking

  • Submission method: ___________
  • Confirmation number: ___________
  • Follow-up call scheduled: ___________
  • Decision received: ___________

FAQ

How long does Aetna take to process Firazyr renewals in Ohio? Standard renewals take 5-10 business days through the provider portal, up to 15 days by fax. Expedited requests are processed within 72 hours.

What if Firazyr is removed from my plan's formulary? You can request a formulary exception with clinical documentation showing medical necessity and contraindications to covered alternatives.

Can I appeal if Aetna reduces my authorized quantity? Yes. Document your historical usage patterns and have your HAE specialist justify the quantity based on attack frequency and severity.

Does step therapy apply to Firazyr renewals? If you're already established on Firazyr, step therapy typically doesn't apply to renewals unless you've had a significant gap in coverage.

What's the difference between internal and external appeals in Ohio? Internal appeals are reviewed by Aetna's medical staff. External appeals are reviewed by independent medical experts through Ohio's Department of Insurance and are binding on Aetna.

How do I expedite my renewal if I'm having frequent attacks? Have your HAE specialist call Aetna at 1-866-752-7021 to request expedited review with clinical justification for urgent need.

At Counterforce Health, we help patients navigate complex insurance appeals for specialty medications like Firazyr. Our platform analyzes denial letters and creates targeted, evidence-based appeals that align with payer-specific requirements. Visit CounterforceHealth.org to learn how we can help streamline your appeals process.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for specific coverage decisions. For personalized help with appeals, Counterforce Health provides specialized support for complex insurance denials.

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