Priority Health: Izervay Payer Policy (Beta Access)

TABLE OF CONTENTS 

• Medicare Part B 

MEDICARE PART B

• HCPCS code(s): J2782
• Precertification required?:  Yes - (Click here for full policy)
• Step therapy required: Not Specified -  (Click here for full policy)
• Provider fax form: Izervay Fax Form (✅ Available in SamaCare) 
• FDA-Approved Indications: Not Specified
• Recommended Dose: Not Specified
• Other Pertinent Information:
  • Medicaid & Commercial Coverage:
    • Not Covered 
  • Required Medical Information
  • Exclusion Criteria
  • Other Criteria