Aetna: Syfovre Payer Policy (Beta Access)

TABLE OF CONTENTS 

• Medicare Part B
• Commercial

MEDICARE PART B

• HCPCS code(s): J2781
• Precertification required?:Yes (Click here for full policy)
• Step therapy required: No 
• Provider fax form: Syfovre Fax Form ✅ Available in SamaCare
• FDA-Approved Indications:
• Recommended Dose: Not Provided
• Other Pertinent Information:
  • Initial Approval Criteria
  • Documentation
  • Exclusion
  • Continuation Criteria

COMMERCIAL

• HCPCS code(s): J2781 
• Precertification required?: Yes (Click here for full policy)
• Step therapy required: Not Provided
• Provider fax form: Syfovre Fax Form (✅ Available in SamaCare) 
• FDA-Approved Indications: Not Provided
• Recommended Dose:
• 
  
• Other Pertinent Information:
  • Initial Approval Criteria
  • Exclusion
  • Continuation Criteria