Izervay (avacincaptad pegol) — Coverage Criteria for Geographic Atrophy
Policy governs prior authorization, coverage criteria, dosing limits, and coding for Izervay (avacincaptad pegol) used to treat geographic atrophy secondary to age-related macular degeneration under the medical benefit for Anthem members.
Removed limit of 12 months of use per label.
Clarified dosing every 28 days +/- 7 days.
Coding reviewed and multiple ICD-10-CM codes removed and updated; HCPCS J2782 (avacincaptad pegol) included.
Coverage and Medical Necessity Criteria
Initial therapy / Medical necessity
Covered when ALL of the following are met:
Approval duration: 1 year
Geographic atrophy that is secondary to a condition other than age-related macular degeneration (including but not limited to Stargardt disease, cone-rod dystrophy, or toxic maculopathies) is excluded from coverage for Izervay (avacincaptad pegol).
Use of Izervay is not approved when any of the following contraindications or disqualifying clinical situations are present: a history of or active choroidal neovascularization / wet age-related macular degeneration; an ocular or periocular infection; or active intraocular inflammation. Requests will also not be approved when the stated coverage criteria are not met.
Billing Codes, Dosing, and Frequency
| J2782 | Injection, avacincaptad pegol, 0.1 mg [Izervay] |
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