By Counterforce Health Team in Firazyr (icatibant injection) —

The Requirements Checklist to Get Firazyr (Icatibant) Covered by Blue Cross Blue Shield in Georgia

Answer Box: Your Fastest Path to Firazyr Coverage

Blue Cross Blue Shield Georgia requires prior authorization for Firazyr (icatibant) with specific criteria: confirmed HAE diagnosis (ICD-10 D84.1), specialist prescription, and documented attack history. The fastest approval path: (1) Submit complete PA with lab results showing abnormal C1-INH levels, (2) Include specialist letter documenting failed alternatives or contraindications, and (3) Use HCPCS J1744 with correct NDC codes. If denied, you have 180 days to appeal internally, then 60 days for Georgia's external review process.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding and Billing Essentials
  5. Documentation Packet Checklist
  6. Submission Process
  7. Specialty Pharmacy Requirements
  8. After Submission: What to Expect
  9. Common Denial Prevention Tips
  10. Appeals Process in Georgia
  11. One-Page Quick Reference

Who Should Use This Checklist

This guide is for patients with hereditary angioedema (HAE) and their healthcare providers seeking Firazyr (icatibant) coverage through Blue Cross Blue Shield in Georgia. You'll need this if you're experiencing acute HAE attacks and require on-demand treatment that works faster than traditional therapies.

Expected outcome: Following this checklist increases your chances of first-submission approval and provides a clear appeals pathway if initially denied. Most well-documented cases with proper clinical justification receive approval within 30 days.

Member & Plan Basics

Coverage Requirements

  • Active BCBS Georgia membership with prescription drug benefits
  • Plan type compatibility: Most commercial and ACA marketplace plans cover Firazyr with prior authorization
  • Deductible considerations: High-deductible plans may require meeting annual deductible first
  • Authorization status: Prior authorization always required for Firazyr
Tip: Check your member portal or call the number on your insurance card to confirm your plan includes specialty drug coverage before starting the PA process.

Clinical Criteria Requirements

Primary Indication

  • FDA-approved use: Acute treatment of HAE attacks in adults (18+ years)
  • Diagnosis requirement: Confirmed hereditary angioedema with ICD-10 code D84.1
  • Specialist involvement: Prescribed by or in consultation with allergist, immunologist, hematologist, pulmonologist, or medical geneticist

Laboratory Evidence Required

Blue Cross Blue Shield Georgia requires documented proof of HAE through:

  • Low C4 levels (complement component 4)
  • Abnormal C1 esterase inhibitor (either low levels or dysfunction)
  • Attack history: Documented moderate to severe attacks affecting skin, abdomen, or airways

Dosing and Quantity Limits

Parameter Limit Clinical Notes
Maximum per attack 90 mg (3 injections) May repeat every 6 hours
Monthly limit 12 injections (360 mg) Covers up to 4 attacks per 28 days
Annual units 400 units per 28 days Based on HCPCS J1744 billing

Source: BCBS Georgia Specialty Drug Policy

Coding and Billing Essentials

Required Codes

  • ICD-10 Diagnosis: D84.1 (Defects in the complement system)
  • HCPCS J-Code: J1744 (Injection, icatibant, 1 mg)
  • NDC Numbers: 54092-0702-01 (single syringe) or 54092-0702-03 (3-pack)
  • Units: 30 units per 30 mg syringe

Billing Modifiers

  • JB modifier: May be required for subcutaneous administration
  • Place of Service: 11 (office) or 12 (home) for self-administration
Note: Always verify the exact NDC on your product packaging, as codes can vary by manufacturer lot.

Documentation Packet Checklist

Provider Requirements

Medical Necessity Letter must include:

  • Confirmed HAE diagnosis with subtype (Type I, II, or normal C1-INH)
  • Laboratory results (C1-INH levels, C4 levels, functional assays)
  • Detailed attack history (frequency, severity, locations)
  • Previous treatments tried and outcomes
  • Clinical rationale for Firazyr over alternatives
  • Self-administration training documentation

Supporting Documents

  • Complete prior authorization form
  • Recent lab results (within 12 months)
  • Specialist consultation notes
  • Attack diary or log
  • Insurance card copy
  • Prescription with correct ICD-10 code

From our advocates: "We've seen the biggest difference in approval rates when providers include a detailed attack log showing both frequency and severity. Insurers want to see that patients truly need rapid-acting treatment, not just convenience. A three-month attack diary with symptom descriptions often tips the scale toward approval."

Submission Process

Step-by-Step Submission

  1. Gather all documents from checklist above
  2. Complete BCBS PA form (available on provider portal)
  3. Submit via preferred method:
    • Online: BCBS provider portal (fastest)
    • Fax: Check current fax number on PA form
    • Mail: Include tracking for paper submissions

Timeline Expectations

  • Acknowledgment: 3-5 business days
  • Standard decision: 30 days maximum
  • Expedited decision: 72 hours (if urgent medical need)
  • Pre-service appeals: 15 days

Specialty Pharmacy Requirements

Blue Cross Blue Shield Georgia typically requires Firazyr to be dispensed through their specialty pharmacy network.

Network Pharmacies

  • Accredo (most common for BCBS)
  • CVS Specialty
  • Express Scripts Specialty

Transfer Process

  1. Verify network status of your preferred pharmacy
  2. Coordinate with prescriber for electronic prescription
  3. Confirm delivery logistics for temperature-sensitive medication
  4. Verify patient training for self-administration

After Submission: What to Expect

Tracking Your Request

  • Confirmation number: Record from submission
  • Status checks: Weekly until decision
  • Contact method: Member services phone line
  • Documentation: Keep copies of all communications

Possible Outcomes

  • Approved: Coverage begins immediately
  • Approved with conditions: May include quantity limits or step therapy requirements
  • Denied: Detailed denial letter with specific reasons and appeal rights

Common Denial Prevention Tips

Five Most Common Pitfalls

Pitfall Prevention Strategy
Incomplete HAE diagnosis Include both C1-INH and C4 lab results with reference ranges
Missing step therapy documentation Document why alternatives (Berinert, Kalbitor) are inappropriate
Inadequate attack history Provide detailed 3-6 month attack log with severity ratings
Wrong specialist Ensure prescriber is board-certified in relevant specialty
Prophylactic use request Clearly state "for acute attack treatment only" in all documentation

Documentation Quality Tips

  • Use specific medical terminology in provider letters
  • Include guideline references from WAO or AAAAI when applicable
  • Attach original lab reports, not just summary values
  • Provide complete medication history including dates and outcomes

Appeals Process in Georgia

If your initial request is denied, Georgia provides robust appeal rights through state-supervised external review.

Internal Appeal (First Step)

  • Timeline: Must file within 180 days of denial
  • Decision deadline: 30 days for standard, 72 hours for expedited
  • Required documents: Appeal form, original denial letter, additional medical justification

External Review (Second Step)

  • Eligibility: Available after internal appeal denial
  • Filing deadline: 60 days from final internal denial
  • Process: Georgia Department of Insurance assigns independent reviewers
  • Cost: Free for consumers
  • Decision: Binding on insurance company

Georgia-Specific Resources

  • Consumer Services Hotline: 1-800-656-2298
  • Online complaint form: Available on Georgia DOI website
  • Georgians for a Healthy Future: Nonprofit providing appeals assistance

Source: Georgia Department of Insurance Consumer Guide

For complex cases involving specialty medications like Firazyr, Counterforce Health specializes in turning insurance denials into successful appeals by analyzing payer policies and crafting targeted, evidence-backed responses that align with each plan's specific requirements.

One-Page Quick Reference

Pre-Submission Checklist

  • HAE diagnosis confirmed (ICD-10 D84.1)
  • Lab results: C1-INH and C4 levels
  • Specialist prescription or consultation
  • Attack history documented (3+ months)
  • Previous treatments documented
  • Self-administration training completed
  • Correct codes: J1744, appropriate NDC
  • PA form completed and signed

Submission Essentials

  • Submit via BCBS provider portal when possible
  • Include all required attachments
  • Request confirmation number
  • Set calendar reminder for 30-day decision deadline

If Denied

  • Review denial letter for specific reasons
  • File internal appeal within 180 days
  • Gather additional supporting evidence
  • Consider peer-to-peer review request
  • Prepare for external review if needed (60-day deadline)

Emergency Situations

  • Request expedited review (72-hour decision)
  • Document urgent medical need
  • Consider concurrent external review request
  • Contact Georgia DOI if delays occur

Disclaimer: This guide provides general information about insurance coverage processes and should not be considered medical or legal advice. Coverage policies vary by specific plan and may change. Always consult with your healthcare provider about treatment decisions and verify current policy details with your insurance company.

Sources & Further Reading

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