SAJAZIR 30 mg/3mL Injection

Also known as Icatibant. Coverage in California (CMS PDP Region 32).

8 of 12 stand-alone Part D plans in California cover this drug on tier 5.

8 of 8 plans apply a prior authorization, step therapy or quantity limit.

284 Medicare Advantage plans in CA do cover it

Medicare Advantage plans carry their own formularies, separate from stand-alone Part D. A patient on an MA-PD plan may have coverage even where no PDP lists the drug. CA: 284 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$495.6245	$8,921.2418 units	Prior authorization Quantity limit 36 per 60 days
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$495.6245	$8,921.2418 units	Prior authorization Quantity limit 36 per 60 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity.

See coverage in all 39 regions →