Product Details

Firazyr

Icatibant
30 mg/3 mL
Solution for Subcutaneous Injection
Single-Use 3-mL Pre-Filled Syringe

DIN/PIN/NPN

02425696

Manufacturer

Takeda Canada Inc.

Formulary Listing Date

2015-11-05  

Unit Price

2700.0000

Amount MOH Pays

2025.0000

Coverage Status

Off-Formulary Interchangeable Exceptional Access Program Product

ODB Formulary Therapeutic Classification

Therapeutic Note

NO

ATC Code

B06AC02

Interchangeable Products

DIN/ PIN/ NPN Brand name Unit Price Amount MOH pays
02425696 Firazyr 2700.0000 2025.0000
02547562 Icatibant Injection 2025.0000 2025.0000
 

LU Clinical Criteria

NO  

EAP Criteria

Therapeutic Class Reimbursement Criteria
Blood Modifiers

Icatibant

  • Brand(s): Firazyr
  • Dosage Form/Strength: 30 mg/3 mL prefilled syringe

For the treatment of acute attacks of type I or type II hereditary angioedema (HAE) in adults with lab confirmed c1-esterase inhibitor deficiency if the following conditions are met: 

  1. Treatment of acute non-laryngeal attacks of at least moderate severity; OR 

  1. Treatment of acute laryngeal attacks; AND 

  1. Must be prescribed by physicians (e.g., immunologists, allergists or hematologists) with experience in the treatment of HAE. 

Notes: 

  • Documentation of diagnosis (e.g. patient and family history, symptoms, lab test results) must be provided. 

  • For acute non-laryngeal attacks, documentation of severity (frequency, location, and degree of swelling) must be provided 

Doses for acute treatment are limited to a single dose for self-administration per attack. 

Duration of Approval: Lifetime

EAP Drug Request Form:

Standard Form for EAP Drug Requests

Product Monograph

View Monograph