Priority Health: Syfovre Payer Policy (Beta Access)

TABLE OF CONTENTS 

• Medicare Part B 
• Commercial
• Medicaid

MEDICARE PART B

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

COMMERCIAL

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

MEDICAID

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