SAJAZIR 30 mg/3mL Injection

Also known as Icatibant. Coverage in New York (CMS PDP Region 03).

6 of 10 stand-alone Part D plans in New York cover this drug on tier 5.

6 of 6 plans apply a prior authorization, step therapy or quantity limit.

129 Medicare Advantage plans in NY 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. NY: 129 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)$35.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1694.4300	$30,499.7418 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1694.4300	$30,499.7418 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1750.9001	$47,274.3027 units	Prior authorization Quantity limit 27 per 30 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 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 →