Prior Authorization Required

Prior authorization is required for both initiation and continuation of therapy. Requests must include sufficient documentation to allow medical necessity review; incomplete submissions may be denied or returned for additional information.

• Prior authorization required for initiation and continuation of Syfovre (pegcetacoplan) and Izervay (avacincaptad pegol).
• Include documentation with initial and renewal requests as described below.
• Approval duration: 12 months when criteria are met.

Combination Therapy Prohibited

The requested medication must not be used in combination with the other agent. Combination therapy with Syfovre and Izervay is prohibited; do not request both agents concurrently for the same eye. There is no allowable sequencing or step-therapy between these agents within the same treatment period.

• Syfovre must not be used in combination with Izervay.
• Izervay must not be used in combination with Syfovre.
• Concurrent or sequential requests that imply combined use for the same eye will be denied.

Required Documentation for Prior Authorization

Submit the following documentation with initial prior authorization requests and include updated/ongoing documentation for continuation requests. Failure to provide required documentation is a common trigger for denial.

• Chart notes or medical record documentation confirming diagnosis of geographic atrophy (GA) secondary to age-related macular degeneration.
• Imaging confirmation: Fundus autofluorescence (FAF), optical coherence tomography (OCT), or other ophthalmic imaging confirming GA.
• Lesion measurements: Total GA lesion area (documented in mm²). If multifocal, documentation that at least one focal lesion is ≥ 1.25 mm² and total GA lesion size is ≥ 2.5 and ≤ 17.5 mm².
• Prescriber specialty: Indication that the medication is prescribed by or in consultation with an ophthalmologist.
• For continuation requests: Evidence of positive clinical response (e.g., reduction or stabilization in rate of vision decline, reduced risk of severe vision loss, stabilization/normalization or reduction in total GA lesion area).
• Relevant exclusions: Documentation ruling out GA due to other etiologies (e.g., Stargardt disease, cone-rod dystrophy, toxic maculopathies), absence of ocular or periocular infection, and absence of active intraocular inflammation.
• For continuation: documentation of no history of or active choroidal neovascularization or exudative AMD (if applicable per agent criteria).

Denial Triggers / Common Missing Documentation

Common reasons claims or prior authorization requests are denied — ensure submissions address these items to reduce denials.

• Missing diagnostic confirmation or absent ophthalmic imaging to verify GA secondary to AMD.
• Lesion size not documented or outside of required range (total GA lesion size < 2.5 mm² or > 17.5 mm²; if multifocal, focal lesion < 1.25 mm²).
• Prescriber is not an ophthalmologist and no consultation with an ophthalmologist is documented.
• Requested therapy is for GA due to an excluded etiology (e.g., Stargardt disease).
• Concurrent use or documentation suggesting combination therapy with the alternate agent (Syfovre and Izervay).
• Active ocular infection or intraocular inflammation documented, or history of choroidal neovascularization when exclusion applies.
• For continuation: lack of documented positive clinical response or absence of follow-up imaging/clinical notes.