CareCost Prior authorization
Required
Check what the payer requires before you schedule Monoferric.
15 payers, 122 rules, and 9 of them make you fail another IV iron first.
15 payer policy sets hold a ferric derisomaltose policy · source-linked · reviewed August 2026
Aetna + iron-deficiency anemia with oral iron failure is shown as a live example until you choose a payer.
This payer requires an approval on file before Monoferric is purchased or administered for this member.
Precertification of Feraheme, Ferrlecit, Injectafer, Monoferric, and Venofer are required of all Aetna participating providers and members in applicable plan designs.
Covered under ICD-10 E83.10.
Aetna considers ferric derisomaltose (Monoferric) intravenous iron therapy medically necessary for the following indications: Treatment of members 18 years of age and older who have documented iron deficiency anemia with an unsatisfactory response, intolerance or contraindication to oral iron administration
What opens in CareCost
Aetna · Monoferric · IDA, oral iron failed or not tolerated
For every requirement: the exact payer criteria, the source citation, a check-off, and a save to the patient’s chart.
In CareCost: check off each requirement · save to the patient · print for the chart
Aetna · Monoferric · IDA, oral iron failed or not tolerated
You have already checked the policy, indication and covered dose. Open the remaining requirements and work them as a patient checklist.
CareCost tracks Monoferric coverage requirements across 15 payer policy sets.
Aetna · Anthem / Elevance · Cigna · Independence Blue Cross · Capital BlueCross · BCBS plans + more
Coverage clearance is only the first step.
CareCost carries the same patient through the entire workflow.
Finish this patient’s estimate →13 of 15 commercial payers with a ferric derisomaltose policy require prior authorization outright. Diagnosis coding, dosing limits and clinical criteria differ payer by payer. CareCost has not found a payer in this corpus that carries no ferric derisomaltose policy at all — every payer checked has one.
Why this one is worth reading closely: a single 1,000 mg Monoferric visit prices at $2,174.84 allowed at Medicare’s Q3 2026 rate ($2,107.70 drug plus $67.14 for the infusion), and getting there can take two gates, not one. 13 of 15 payers require documented oral-iron failure first — all but BCBS Arkansas and Wellmark.
Then 9 of those 15 also require a documented failure of another IV iron before Monoferric itself is paid: BCBS Kansas wants failure on TWO of four named products (Feraheme, Ferrlecit, INFeD or Venofer), and Independence and Wellmark list Monoferric as non-preferred outright. Skip either gate in the chart and the authorization comes back denied no matter what the diagnosis says.
13 require PA · 14 have clinical criteria · 1 restrict site of care · 5 list contraindication exclusions
13 of the 15 payers CareCost has read require prior authorization for ferric derisomaltose outright. Aetna’s rule is class-wide rather than Monoferric-specific: “Precertification of Feraheme, Ferrlecit, Injectafer, Monoferric, and Venofer are required of all Aetna participating providers and members in applicable plan designs.” The other 2 are criteria-based: Independence Blue Cross carries no formal prior-authorization rule at all and reviews its own non-preferred-product criteria instead, and Excellus BCBS’s rule states plainly that prior authorization is not required, though it still checks the diagnosis and dosing criteria below.
13 of the 15 payers write oral-iron failure or intolerance into a rule — every payer except BCBS Arkansas and Wellmark, whose only gate is failure of another IV iron. Anthem and Florida Blue set a four-week trial: Anthem requires “a four (4) week trial of and inadequate response, or intolerance to oral iron supplementation,” and Florida Blue requires the member to have “tried and failed four week trial of oral iron therapy.”
Capital BlueCross and BCBS Kansas set the shortest bar, 14 days: “an intolerance or inadequate response to a minimum of 14 days of oral iron.” Independence and Premera set the longest, three months, before Monoferric is considered.
Clear the oral-iron gate and 9 of the 15 payers still require a documented failure of another IV iron before Monoferric specifically is paid. BCBS Kansas sets the highest bar in the corpus: “Patient must have a contraindication, intolerance, or failure to TWO of the following products, Feraheme, Ferrlecit, INFeD, or Venofer prior to consideration of Monoferric.”
Aetna requires “a contraindication, intolerance or ineffective response to the available equivalent alternative intravenous iron products” — generic ferumoxytol, generic iron sucrose, generic sodium ferric gluconate and INFeD. Anthem applies a formulary step instead of naming products: “a trial and inadequate response or intolerance to two (2) preferred agents.”
Independence and Wellmark list Monoferric as non-preferred outright. Independence’s rule reads “the nonpreferred product is eligible for coverage when the individual has documentation of a contraindication, intolerance” — against two or more of the plan’s own preferred IV-iron products. Wellmark requires “a documented inadequate response, intolerable adverse event, or a contraindication to the preferred products” — Feraheme, Ferrlecit, Infed and Venofer.
Blue Shield of California requires “inadequate response or intolerable side effect to preferred generic IV iron products [iron sucrose (generic for Venofer) and ferumoxytol (generic for Feraheme)].” Centene requires failure of Ferrlecit and iron sucrose for the CKD indication, and two of Ferrlecit, INFeD or iron sucrose for the oral-intolerance indication — with its step-therapy rule waived for Illinois HIM requests as of 1/1/2026 (“the step therapy requirements below do not apply as of 1/1/2026 per IL HB 5395”).
Cigna’s non-dialysis CKD indication requires “at least one of the following: INFeD, sodium ferric gluconate complex (Ferrlecit, generics), Venofer.” Premera requires an inadequate response “to at least 1 of the following preferred IV iron products” — Ferrlecit, generic sodium ferric gluconate complex, INFeD or Venofer.
The other 6 payers — BCBS Arkansas, Florida Blue, BCBS Minnesota, BCBS South Carolina, Capital BlueCross and Excellus — gate on oral iron and lab thresholds only, with no named IV-iron alternative and no formulary step in the rule.
7 of the 15 payers name a ferritin threshold and 6 name a transferrin saturation (TSAT) threshold. BCBS Kansas requires “Ferritin <100 ng/mL AND transferrin saturation (TSAT) <40%” for the CKD pathway, or “ferritin <100 ng/mL AND transferrin saturation (TSAT) <20%” for oral-iron intolerance. Independence Blue Cross sets a lower bar for oral-iron failure — ferritin under 30 ng/mL or TSAT under 20%.
No payer in this corpus asks for a serum phosphate level; this label carries no hypophosphatemia warning to check against.
BCBS Kansas, BCBS Minnesota and Capital BlueCross cap Monoferric at 100 billable units (1,000 mg) per 35 days — all three read “100 billable units per 35 days.” J1437 bills per 10 mg, so the number on the claim is 100 units, not 1,000. Cigna caps it at “1000 mg given intravenously per 30 days,” Anthem at “1000 mg per day,” Florida Blue at “maximum 2 doses per treatment course,” Blue Shield of California at one dose “covered as often as every 28 days,” and Centene at “1000 mg elemental iron (10 mL) per infusion/injection.”
BCBS Kansas and BCBS Minnesota renew authorization every 35 days: “Prior authorization validity may be renewed for 35 days when initial criteria are met.” Blue Shield of California reauthorizes “yearly, based on continued response to therapy,” and Capital BlueCross renews against the same initiation criteria rather than a fixed calendar.
Independence Blue Cross is the only payer in this corpus with a class-wide restriction on where Monoferric can be administered, covering every IV-iron product on its formulary rather than Monoferric alone. Its rule reads: “The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting.”
Monoferric shares its clinical territory with five other billable IV-iron products — Injectafer (J1439), Venofer (J1756), Feraheme (Q0138), Ferrlecit (J2916) and INFeD (J1750). The price spread between them is part of what shows up as a step requirement at 9 of the 15 payers in this corpus.
| Product | Code | Per 1,000 mg of iron (Q3 2026) |
|---|---|---|
| Ferrlecit | J2916 | $175.76 |
| Venofer | J1756 | $227.00 |
| Feraheme | Q0138 | $370.00 |
| INFeD | J1750 | $379.86 |
| Injectafer | J1439 | $1,132.00 |
| Monoferric | J1437 | $2,107.70 |
Monoferric is 9.3× Venofer and 1.9× Injectafer for the iron itself — the most expensive IV iron in the class per milligram. 9 of the 15 payers in this corpus name a specific product from this table, or a generic IV iron requirement, that the patient must fail first.
Anthem is the ninth payer with a step, but it is a formulary rule, not a named-product one: “a trial and inadequate response or intolerance to two (2) preferred agents,” applied class-wide. The other 6 payers — BCBS Arkansas, Florida Blue, BCBS Minnesota, BCBS South Carolina, Capital BlueCross and Excellus — do not name any product or formulary step; they gate on oral iron and lab thresholds only.
Every payer in this corpus that covers ferric derisomaltose still requires oral-iron failure and the diagnosis codes below regardless — the second gate is layered on top of that one, not a replacement for it.
Iron-deficiency anemia carries a parent ICD-10 category that requires a fourth character to be billable. A claim coded to the bare category alone will be rejected.
| Indication | ICD-10 | Notes |
|---|---|---|
| Iron-deficiency anemia, oral iron failed or not tolerated | D50.9 | Reference code used by this site |
| Iron-deficiency anemia, other/unspecified etiology | D50.0 / D50.8 | Also billable; the bare D50 is a category code and is not |
| Iron-deficiency anemia in non-dialysis CKD | D63.1 | Pairs with a CKD staging code, N18.30–N18.5 |
Aetna is a coding exception worth flagging: the Clearance corpus tags Aetna’s own covered-indication rule with E83.10 (disorder of iron metabolism, unspecified) rather than a D50.x code. That tag describes how Aetna’s policy language was filed in the corpus, not a claim-level billing instruction — D50.9 remains the reference code this site uses for the oral-iron-failure indication, and a biller should confirm Aetna’s own claim requirements before coding to anything else.
Verified against the NLM Clinical Table Search Service on 2026-09-19.
A search of the CMS Medicare Coverage Database (CareCost’s Medicare coverage library) confirms there is no drug-specific National Coverage Determination, Local Coverage Determination or Billing & Coding Article for J1437 in the CMS Medicare Coverage Database. Your Medicare Administrative Contractor (MAC) decides Part B coverage case by case on medical necessity, starting from the FDA-approved indications.
This is the Original Medicare answer. A Medicare Advantage plan administers the same Part B benefit but can layer its own prior-authorization and site-of-care rules on top — check the plan’s own policy rather than assuming the Original Medicare rules carry over.
The label gives one route for every Monoferric dose: dilution in 100 to 500 mL of 0.9% sodium chloride (more than 1 mg iron per mL) and infusion over at least 20 minutes, billed 96365 ($67.14). There is no push option, so 96374 is wrong here — the opposite of Injectafer, whose typical dose is a push billed 96374. At 20 minutes the infusion never reaches the 96366 additional-hour line.
Payer citation language above is drawn from CareCost’s own ferric derisomaltose policy corpus (15 payers, 122 rules). Check the specific payer’s language →
It depends on the payer and plan. 13 of the 15 ferric derisomaltose policies CareCost has read require prior authorization outright. The other 2 are criteria-based — Independence Blue Cross carries no formal PA rule at all, and Excellus BCBS documents that PA is not required, though it still checks the criteria below. Check this patient’s payer →
Not the bare D50. Iron-deficiency anemia bills to a fourth-character child of the category — D50.9 is the code this site uses as the reference patient, and D50.0 and D50.8 are also billable. The non-dialysis CKD indication pairs D63.1 with a CKD staging code, N18.30 through N18.5. Check the diagnosis coding →
It clusters on one number. BCBS Kansas, BCBS Minnesota and Capital BlueCross cap it at 100 billing units (1,000 mg) per 35 days — 100 units, not 1,000, is what belongs on the claim, since J1437 bills per 10 mg. Cigna caps it at 1,000 mg per 30 days and Anthem at 1,000 mg per day. See the quantity-limit detail →
Oral-iron failure or intolerance, first: 13 of the 15 payers CareCost has read write it into a rule — every payer except BCBS Arkansas and Wellmark. Then, for 9 of the 15, documented failure of another IV iron first; BCBS Kansas wants failure on two of four named products. Seven payers also name a ferritin threshold and six a transferrin saturation (TSAT) threshold — no payer in this corpus asks for a serum phosphate level. Open patient clearance →
Data current: payer policies Aug 2026 · reviewed dates come from each payer
Payer medical and pharmacy policies · prior-authorization criteria · clinical coverage criteria. ICD-10 codes verified against the NLM Clinical Table Search Service. Medicare coverage and fee-schedule amounts from the CMS Medicare Coverage Database and the Medicare Physician Fee Schedule. Every CareCost requirement links back to its source policy.