Aetna: Izervay Payer Policy (Beta Access)

TABLE OF CONTENTS 

• Medicare Part B
• Commercial

MEDICARE PART B

• HCPCS code(s): J2782
• Precertification required?: Yes (Click here for full policy) 
• Step therapy required: No
• Provider fax form: Izervay Fax Form (✅ Available in SamaCare) 
• FDA-Approved Indications: 
• Recommended Dose: Not Provided
• Other Pertinent Information:
  • Initial Approval Criteria
  • Documentation
  • Exclusion
  • Continuation Guidelines - Not Provided

COMMERCIAL

• HCPCS code(s): J2782
• Precertification required?: Yes (Click here for full policy)
• Step therapy required: Not Provided 
• Provider fax form: Izervay Fax Form (✅ Available in SamaCare) 
• FDA-Approved Indications: Not Provided
• Recommended Dose
• Other Pertinent Information:
  • Initial Approval Criteria
  • Exclusion
  • Continuation Criteria