3 ML icatibant 10 MG/ML Prefilled Syringe [Sajazir]
icatibant
RxCUI: 2569480
What the CMS Formulary Data Shows for 3 ML icatibant 10 MG/ML Prefilled Syringe [Sajazir]
Per the CMS 2026 Part D formulary file, 3 ML icatibant 10 MG/ML Prefilled Syringe [Sajazir] (RxNorm concept RXCUI 2569480, generic name icatibant) appears on 195 distinct formulary files spanning 3,480 Medicare Part D plan offerings - 68.7% of enrollable Part D products, mid-range placement; shopping across contracts changes access. Tier placement ranges from Tier 1 to Tier 6, with a cross-plan average of Tier 4.3.
Real-world access to 3 ML icatibant 10 MG/ML Prefilled Syringe [Sajazir] depends on utilization management as much as tier placement: 99% of covering formularies require prior authorization. 0% require step therapy. 81.5% apply quantity limits.
Historical spending context from the CMS Medicare Part D Drug Spending Dashboard shows 43 Part D beneficiaries filled 3 ML icatibant 10 MG/ML Prefilled Syringe [Sajazir] in 2023, with total plan-and-beneficiary spending of $2,908,596 and an average per-beneficiary annual cost of $67,641.77. The plan-by-plan detail below lists exactly which PDP and MA-PD contracts carry 3 ML icatibant 10 MG/ML Prefilled Syringe [Sajazir] today.
Coverage Details
- Formularies covering
- 195
- Plans covering
- 3,480
- Coverage rate
- 68.7%
- Tier range
- Tier 1 – Tier 6
- Average tier
- Tier 4, Non-Preferred
Restrictions
- Prior authorization required
- 99% of formularies
- Step therapy required
- 0% of formularies
- Quantity limits
- 81.5% of formularies
2023 Medicare Spending
- Beneficiaries
- 43
- Total spending
- $2,908,596
- Avg per beneficiary
- $67,641.77
Tier Distribution Across Plans
Medicare Advantage Plans (MA-PD) Covering 3 ML icatibant 10 MG/ML Prefilled Syringe [Sajazir]
100 Medicare Advantage plans with Part D drug coverage include this drug.
| Plan | Insurer | Tier | PA | Premium | States |
|---|---|---|---|---|---|
| Sentara Community Complete Select (HMO D-SNP) | SENTARA HEALTH PLANS | T1 | Yes | $0 | VA |
| Sentara Community Complete (HMO D-SNP) | SENTARA HEALTH PLANS | T1 | Yes | $0 | VA |
| Florida Complete Care-Duals VIP (HMO-POS D-SNP) | HPMP OF FLORIDA, INC. | T1 | Yes | $0 | FL |
| ElderServe MAP (HMO D-SNP) | ELDERSERVE HEALTH, INC. | T1 | Yes | $0 | NY |
| Cooperative Advantage (HMO D-SNP) | GROUP HEALTH COOPERATIVE OF EAU CLAIRE | T1 | Yes | $0 | WI |
| Longevity Health Plan (PPO I-SNP) | LONGEVITY HEALTH PLAN OF NEW JERSEY INSURANCE COMP | T1 | Yes | $0 | NJ |
| Mercy Care Advantage (HMO D-SNP) | MERCY CARE | T1 | Yes | $0 | AZ |
| Mercy Care Advantage (HMO D-SNP) | MERCY CARE | T1 | Yes | $0 | AZ |
| Mercy Care Advantage (HMO D-SNP) | MERCY CARE | T1 | Yes | $0 | AZ |
| Elderplan Plus Long-Term Care (HMO-POS D-SNP) | ELDERPLAN, INC. | T1 | Yes | $0 | NY |
| Health Choice Pathway (HMO D-SNP) | HEALTH CHOICE ARIZONA, INC. | T1 | Yes | $0 | AZ |
| Healthfirst CompleteCare (HMO D-SNP) | HEALTHFIRST HEALTH PLAN, INC. | T1 | Yes | $0 | NY |
| IMCare Classic (HMO D-SNP) | ITASCA MEDICAL CARE | T1 | Yes | $0 | MN |
| Johns Hopkins Advantage MD D-SNP (HMO D-SNP) | HOPKINS HEALTH ADVANTAGE, INC. | T1 | Yes | $0 | MD |
| MetroPlus UltraCare (HMO D-SNP) | METROPLUS HEALTH PLAN, INC. | T1 | Yes | $0 | NY |
| Upper Peninsula Health Plan MI Coordinated Health (HMO D-SNP) | UPPER PENINSULA HEALTH PLAN, LLC | T1 | Yes | $0 | MI |
| CareSource Dual Advantage (HMO D-SNP) | CARESOURCE GEORGIA CO. | T1 | Yes | $0 | GA |
| Senior Whole Health SCO (HMO D-SNP) | SENIOR WHOLE HEALTH, LLC | T1 | Yes | $0 | MA |
| Senior Whole Health SCO NHC (HMO D-SNP) | SENIOR WHOLE HEALTH, LLC | T1 | Yes | $0 | MA |
| Molina One Care (HMO D-SNP) | SENIOR WHOLE HEALTH, LLC | T1 | Yes | $0 | MA |
| HAP CareSource MI Coordinated Health (HMO D-SNP) | HAP CARESOURCE | T1 | Yes | $0 | MI |
| CareAdvantage (HMO D-SNP) | SAN MATEO HEALTH COMMISSION | T1 | Yes | $0 | CA |
| Gold Coast Health Plan Total Care Advantage (HMO D-SNP) | Ventura County Medi-Cal Managed Care Commission | T1 | Yes | $0 | CA |
| Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP) | Health Care Service Corporation | T1 | Yes | $0 | NM |
| Blue Cross MA Dual Care Plus Preferred (PPO D-SNP) | Health Care Service Corporation | T1 | Yes | $0 | NM |
| Horizon NJ TotalCare (HMO D-SNP) | HORIZON HEALTHCARE OF NEW JERSEY, INC. | T1 | Yes | $0 | NJ |
| SecureBlue (HMO D-SNP) | HMO Minnesota | T1 | Yes | $0 | MN |
| NaviCare (HMO D-SNP) | FALLON COMMUNITY HEALTH PLAN | T1 | Yes | $0 | MA |
| Hamaspik Medicare Choice (HMO D-SNP) | HAMASPIK, INC. | T1 | Yes | $0 | NY |
| CCA One Care (HMO D-SNP) | COMMONWEALTH CARE ALLIANCE, INC. | T1 | Yes | $0 | MA |
| CCA Senior Care Options (HMO D-SNP) | COMMONWEALTH CARE ALLIANCE, INC. | T1 | Yes | $0 | MA |
| CalOptima Health OneCare Complete (HMO D-SNP) | ORANGE COUNTY HEALTH AUTHORITY | T1 | Yes | $0 | CA |
| Mass General Brigham SCO (HMO D-SNP) | MASS GENERAL BRIGHAM HEALTH PLAN, INC | T1 | Yes | $0 | MA |
| Mass General Brigham One Care (HMO D-SNP) | MASS GENERAL BRIGHAM HEALTH PLAN, INC | T1 | Yes | $0 | MA |
| Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) | GATEWAY HEALTH PLAN, INC. | T1 | Yes | $0 | PA |
| Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) | GATEWAY HEALTH PLAN, INC. | T1 | Yes | $0 | PA |
| Highmark Health Options Duals (HMO D-SNP) | HIGHMARK HEALTH OPTIONS WEST VIRGINIA INC. | T1 | Yes | $0 | WV |
| Highmark Health Options Duals (HMO D-SNP) | HIGHMARK BCBSD, INC. | T1 | Yes | $0 | DE |
| Florida Complete Care (HMO I-SNP) | HPMP OF FLORIDA, INC. | T1 | Yes | $4.80 | FL |
| Florida Complete Care- In The Community (HMO-POS I-SNP) | HPMP OF FLORIDA, INC. | T1 | Yes | $4.80 | FL |
| Longevity Health Plan (HMO I-SNP) | LONGEVITY HEALTH PLAN OF FLORIDA, INC. | T1 | Yes | $4.80 | FL |
| Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP) | HCSC INSURANCE SERVICES COMPANY | T1 | Yes | $4.80 | TX |
| Gold Dialysis & Kidney Complete (HMO-POS C-SNP) | GOLD KIDNEY OF FLORIDA INC | T1 | Yes | $4.80 | FL |
| Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP) | GHS INSURANCE COMPANY | T1 | Yes | $5.00 | OK |
| Longevity Health Plan (HMO I-SNP) | LONGEVITY HEALTH PLAN OF MICHIGAN, INC. | T1 | Yes | $8.80 | MI |
| Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) | GATEWAY HEALTH PLAN, INC. | T1 | Yes | $13.10 | PA |
| Longevity Health Plan (HMO I-SNP) | LONGEVITY HEALTH PLAN OF ILLINOIS, INC. | T1 | Yes | $15.20 | IL |
| Gold Dialysis & Kidney Complete (HMO-POS C-SNP) | GOLD KIDNEY OF ARIZONA | T1 | Yes | $17.00 | AZ |
| Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) | GATEWAY HEALTH PLAN, INC. | T1 | Yes | $17.60 | PA |
| WellSense Added Value (HMO) | BOSTON MEDICAL CENTER HEALTH PLAN, INC. | T1 | Yes | $21.70 | NH |
Frequently Asked Questions
Is 3 ML icatibant 10 MG/ML Prefilled Syringe [Sajazir] covered by Medicare Part D?
Yes, 3 ML icatibant 10 MG/ML Prefilled Syringe [Sajazir] is covered by 3,480 Medicare Part D plans (68.7% of all Part D formularies).
What tier is 3 ML icatibant 10 MG/ML Prefilled Syringe [Sajazir] on Medicare Part D plans?
3 ML icatibant 10 MG/ML Prefilled Syringe [Sajazir] averages Tier 4.3 across Part D plans, ranging from Tier 1 to Tier 6.
Does 3 ML icatibant 10 MG/ML Prefilled Syringe [Sajazir] require prior authorization?
99% of Part D formularies require prior authorization for 3 ML icatibant 10 MG/ML Prefilled Syringe [Sajazir]. Step therapy: 0%. Quantity limits: 81.5%.
How much does Medicare spend on 3 ML icatibant 10 MG/ML Prefilled Syringe [Sajazir]?
In 2023, total Medicare Part D spending on 3 ML icatibant 10 MG/ML Prefilled Syringe [Sajazir] was $2,908,596, covering 43 beneficiaries. The average spend per beneficiary was $67,641.77.
Read our methodology - how this data is sourced, computed, and verified.