Izervay Prior Authorization Resources

Find the right PA form for your patient's payer, get the ICD-10 codes you need, and download appeal templates — all in one place.

Blue Cross Blue Shield of Arkansas - Pharmacy Prior Authorization Form Arkansas Blue Cross Blue Shield
ATRIO Health Plans - Geographic Atrophy Part B Prior Authorization Request FormATRIO Health Plans, Inc.
Blue Cross Blue Shield of Michigan - Medication Authorization Request FormBlue Cross Blue Shield of Michigan
Blue Cross of Idaho - General Prior Authorization Form Blue Cross of Idaho Health Services, Inc.
California - Uniform Prior Authorization FormCalifornia
CDPHP - General Prior Authorization FormCapital District Physicians Health Plan, Inc.

ICD-10 codes for Izervay Prior Authorizations

H35.3111Nonexudative age-related macular degeneration with macular atrophy or geographic atrophy, right eye
H35.3112Nonexudative age-related macular degeneration with macular atrophy or geographic atrophy, left eye
H35.3113Nonexudative age-related macular degeneration with macular atrophy or geographic atrophy, bilateral

Appeal Templates

If the payer denies coverage, these templates help you build a stronger appeal.
Coverage Authorization Appeals Coverage Authorization Appeals resource
Letter of Medical NecessityLetter of Medical Necessity resource
A peer-to-peer review with the payer's medical director can often resolve denials faster than a formal appeal.

Brand Resources

Letter of Medical ExceptionLetter of Medical Exception resource

Support for Getting Your Patient on Izervay

Check coverage & formulary statusVerify PA requirements for your patient's plan.Find savings programsCopay cards, patient assistance, and more.Check medication interactionsScreen prescriptions for harmful drug combinations.