SAJAZIR 30 mg/3mL Injection

Also known as Icatibant. Coverage in Pennsylvania and West Virginia (CMS PDP Region 06).

8 of 12 stand-alone Part D plans in Pennsylvania and West Virginia cover this drug on tier 5.

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

290 Medicare Advantage plans in PA, WV 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. PA: 244 plans · WV: 46 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$6.60/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)$19.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1750.9001	$47,274.3027 units	Prior authorization Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	5Specialty Tier	25%	—	$471.4238	$8,485.6318 units	Prior authorization Quantity limit 18 per 30 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$478.6595	$8,615.8718 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 →