CurrentAetnaPolicy N/A

Izervay (avacincaptad pegol) Medication Precertification Request - Coverage Criteria

Precertification form and requirements for Aetna coverage of Izervay (avacincaptad pegol), capturing patient, prescriber, dispensing, product, diagnosis, and required clinical information for initiation or continuation of therapy.

Policy Summary

PayerAetna

PolicyIzervay (avacincaptad pegol) Medication Precertification Request - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrecertification is required and complete, legible form must indicate start or continuation of treatment with dose and frequency (2 mg monthly, up to 12 months).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1page count

12 momax initial duration

2 mgdose per eye

Aetnapayer

Coverage criteria and indications

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Precertification form completeness: Completed and legible patient, insurance, prescriber, and dispensing provider/administration sections

Fields include patient demographics, Aetna member ID, prescriber NPI/license, place of administration

Clinical diagnosis: Documentation confirming diagnosis of geographic atrophy (GA) secondary to age-related macular degeneration (AMD)

Form asks to indicate primary ICD code and to confirm GA secondary to AMD

Prescriber specialty: Medication to be prescribed by or in consultation with an ophthalmologist

Checkbox on form

Dosing plan: Plan for 2 mg injection into each affected eye once monthly for up to 12 months2 mg monthly up to 12 months

Checkbox on form to indicate this regimen

The precertification form explicitly distinguishes geographic atrophy (GA) secondary to age-related macular degeneration (AMD) from GA that is attributable to other etiologies. The clinical information section asks the provider to confirm whether the patient has GA secondary to AMD and separately asks whether GA is secondary to other conditions (for example, Stargardt disease, cone-rod dystrophy, or toxic maculopathies), ensuring that coverage consideration is specific to GA caused by AMD.

The form makes clear that requests for GA due to conditions other than AMD are not the primary indication solicited. Providers must indicate whether GA is secondary to non-AMD causes on the form, and the separate question for other etiologies reinforces that the precertification process is intended for GA secondary to AMD.

Diagnosis, administration, and billing codes

Diagnosis and administration codesmixed

Primary ICD Code	Field for primary diagnosis ICD code (unspecified in form)
Secondary ICD Code	Field for secondary diagnosis ICD code (unspecified in form)
Other ICD Code	Field for additional diagnosis ICD code(s) (unspecified in form)
Administration code(s) (CPT)	Field to list CPT code(s) for administration (unspecified in form)

inv-05: Maximum documented initial monthly treatment duration — up to 12 months

Maximum initial documented treatment durationUp to 12 months

Typical dosing regimen captured on form2 mg injected into each affected eye once monthly

Form asks about intent for therapy beyond initial periodCheckbox to indicate if medication will be provided beyond 12 months

Prescriber and provider requirements

Prior Authorization

Prior Authorization Required

Precertification is required for Izervay (avacincaptad pegol); the precertification form must indicate whether this is the start of treatment or continuation of therapy and provide product (dose and frequency), diagnosis (ICD codes), and all required clinical information. Complete and legible patient, insurance, prescriber, and dispensing provider information must be provided.

Start or continuation of treatment and start/last treatment dates must be indicated on the form.
Complete patient, insurance, prescriber, dispensing provider, product (dose and frequency), and diagnosis (ICD codes) information required.

Billing Rule

Place of Administration and Billing

Place of administration must be documented on the precertification form. When applicable, include the administration CPT code(s) and the specific administration setting.

Document Place of Administration: Self-administered; Physician's Office; Outpatient Infusion Center; Home Infusion Center; Other.
Document Administration code(s) (CPT) when applicable and include center/agency name and contact information.

Denial Risk

Denial or Delay Risk — Documentation Required

Precertification requests may be denied or delayed if required clinical information is incomplete or the form is not completed and legible. Ensure the clinical checklist is fully answered (diagnosis of GA secondary to AMD vs other causes, ophthalmologist involvement, planned injection schedule, and duration of therapy).

All required clinical questions must be completed in their entirety.
Incomplete or illegible forms increase risk of denial or processing delays.
Include prescriber signature and date on the acknowledgement section.

Drug and condition background

Izervay (avacincaptad pegol) is an intravitreal therapy for geographic atrophy (GA) secondary to age-related macular degeneration (AMD). The precertification form requests confirmation that the medication will be prescribed by or in consultation with an ophthalmologist and documents the typical dosing plan of 2 mg injected into each affected eye once monthly for up to 12 months, with an additional field to indicate intent to continue therapy beyond 12 months.

Key definitions

inv-11: GA secondary to AMD — definition entry for geographic atrophy secondary to age-related macular degeneration.

DefinitionGeographic atrophy (GA) secondary to age-related macular degeneration (AMD)

Distinguishing noteForm differentiates GA secondary to AMD from GA due to other causes (e.g., Stargardt disease, cone rod dystrophy, toxic maculopathies)

Documentation requirementForm requires confirmation that the diagnosis is GA secondary to AMD

Requirements for initial therapy requests

Initial Therapy

Initial therapy requests must specify start date, dose, frequency, and meet diagnosis and prescriber specialty requirements.

Initial therapy documentation: Indicate start of treatment with start date; provide dose and frequency; confirm diagnosis of GA secondary to AMD and ophthalmologist involvement2 mg monthly up to 12 months

Form fields: 'Start of treatment' date, Product Dose and Frequency, checkbox confirming GA secondary to AMD, checkbox confirming ophthalmologist prescribing/consultation

Requirements for continuation of therapy

Continuation Therapy

Continuation requests must document date of last treatment and complete clinical fields.

Continuation documentation: Indicate continuation of therapy and date of last treatment; provide current dosing, diagnosis, and confirm ongoing plan

Form fields: 'Continuation of therapy' with date of last treatment, Product Dose and Frequency, checkbox confirming ongoing plan and GA secondary to AMD

Place of administration

Note

Specify place of administration (office/site of care)

Indicate the place of administration on the form; available options include self‑administered, physician's office, outpatient infusion center, and home infusion center.

Select one Place of Administration option on the D. Dispensing Provider/Administration Information section.