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    v1.0.31
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsBlue Shield CA Izervay Prior Auth | OpenPayer
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    CurrentBlue Shield of CaliforniaPolicy N/A

    Avacincaptad pegol (Izervay)

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    This Commercial Medical Benefit Drug Policy governs coverage and prior authorization for avacincaptad pegol (Izervay) administered for geographic atrophy secondary to age-related macular degeneration under the Blue Shield of California medical benefit.

    Policy Summary
    PayerBlue Shield of California
    PolicyAvacincaptad pegol (Izervay)
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective Date02/01/2026
    Next Review DateN/A
    Key ActionSubmit prior authorization or preservice review for avacincaptad pegol used for geographic atrophy secondary to age-related macular degeneration.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    1Covered condition
    2 mgMaximum dose per affected eye
    Every 3 weeksAdministration frequency
    YearlyCoverage review
    J2782

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Assigned HCPCS code

    Coverage Criteria

    Geographic Atrophy Secondary to Age-Related Macular Degeneration (GA-AMD)

    The following condition requires Prior Authorization/Preservice. Medical necessity is met when all of the following are met:

    Diagnosis of Geographic Atrophy Secondary to Age-Related Macular Degeneration (GA-AMD).

    Continuation Therapy and Covered Dose

    Coverage continues when all of the following are met:

    ALL of the following

    • Continued response to therapy is documented.

      Coverage period is yearly, based on continued response to therapy.

    • The dose does not exceed 2 mg given by intravitreal injection to each affected eye every 3 weeks.

      Covered dose requirement.

    The condition listed in this policy is Geographic Atrophy Secondary to Age-Related Macular Degeneration (GA-AMD).

    Any condition not listed in this policy requires a review to confirm that it is medically necessary. For conditions that have not been approved for intended use by the Food and Drug Administration (i.e., off-label use), the criteria outlined in Health and Safety Code section 1367.21 must be met.

    Initial Therapy

    Initial Therapy for GA-AMD

    Prior authorization/preservice review is required.

    Initial therapy medical necessity

    • The member has geographic atrophy secondary to age-related macular degeneration (GA-AMD).

    Continuation Therapy

    Annual Continuation Review

    Continued coverage is reviewed yearly based on continued response to therapy.

    Continuation therapy

    • Continued response to therapy supports continued coverage at the yearly review.Yearly review
    • Dosing does not exceed 2 mg given by intravitreal injection to each affected eye every 3 weeks.2 mg per affected eye every 3 weeks

    Dose and Administration Limits

    Quantity limits
    DrugAvacincaptad pegol (Izervay)
    Maximum doseNot to exceed 2 mg
    Administration routeIntravitreal injection
    Administration siteEach affected eye
    FrequencyEvery 3 weeks

    Billing and Diagnosis Codes

    Covered HCPCS CodesHCPCSCovered
    J2782Injection, avacincaptad pegol, 0.1 mg
    Covered ICD-10 CodesICD-10Covered
    H35.3113Geographic atrophy secondary to age-related macular degeneration, right eye
    H35.3114Geographic atrophy secondary to age-related macular degeneration, right eye
    H35.3123Geographic atrophy secondary to age-related macular degeneration, left eye
    H35.3124Geographic atrophy secondary to age-related macular degeneration, left eye
    H35.3133Geographic atrophy secondary to age-related macular degeneration, bilateral
    H35.3134Geographic atrophy secondary to age-related macular degeneration, bilateral
    Covered dose
    Covered drugAvacincaptad pegol (Izervay)
    Billing dose basis2 mg maximum per affected eye
    Route of administrationIntravitreal injection
    Administration frequencyEvery 3 weeks

    Authorization, Documentation, and Billing Actions

    Prior Authorization

    Prior Authorization Required for GA-AMD

    Prior authorization/preservice review is required before coverage for avacincaptad pegol (Izervay) for Geographic Atrophy Secondary to Age-Related Macular Degeneration (GA-AMD).

    • Applies to GA-AMD coverage requests.
    • Submit the request before treatment or dispensing, as applicable.
    Documentation Required

    Medical Necessity Documentation

    Submit documentation supporting medical necessity and demonstrating that the member meets all applicable coverage requirements. Documentation may include office chart notes, laboratory results, and other relevant clinical information.

    • Document the diagnosis and clinical facts supporting the request.
    • Include all records needed to establish that medical necessity requirements are met.

    Permitted Administration Settings

    Billing Rule

    Identify office administration

    Record office administration as the place of service when the drug is administered in the office.

    Billing Rule

    Identify hospital outpatient administration

    Record outpatient facility administration as the place of service when the drug is administered in a hospital outpatient setting.

    Billing Rule

    Identify infusion center administration

    Record infusion administration as the place of service when the drug is administered in an infusion center.

    Drug and Policy Background

    Avacincaptad pegol (Izervay) is an ophthalmic agent classified as a complement C5 inhibitor. This policy addresses its administration by intravitreal injection for geographic atrophy secondary to age-related macular degeneration (GA-AMD) under the Blue Shield of California medical benefit.

    Policy Definitions

    GA-AMD
    TermGeographic atrophy secondary to age-related macular degeneration (GA-AMD)
    Policy conditionGeographic atrophy secondary to age-related macular degeneration
    Coverage contextThe condition is listed in the policy for avacincaptad pegol (Izervay).
    Ophthalmic agents
    TermOphthalmic agents
    DefinitionA drug category for agents administered for ophthalmic indications
    Policy drug classAvacincaptad pegol (Izervay) is listed under the ophthalmic agents category.
    Policy Summary
    PayerBlue Shield of California
    PolicyAvacincaptad pegol (Izervay)
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective Date02/01/2026
    Next Review DateN/A
    Key ActionSubmit prior authorization or preservice review for avacincaptad pegol used for geographic atrophy secondary to age-related macular degeneration.
    SourceLink
    On This Page
    Coverage CriteriaInitial TherapyContinuation TherapyDose and Administration LimitsBilling and Diagnosis CodesAuthorization, Documentation, and Billing ActionsPermitted Administration SettingsDrug and Policy BackgroundPolicy Definitions
    Billing Rule

    Billing Documentation Required

    For billing, submit the drug’s assigned HCPCS code as listed in the drug policy together with the corresponding NDC (National Drug Code).

    • Include both the assigned HCPCS code and corresponding NDC.
    • The member’s specific benefit and other utilization management or legal requirements may affect drug coverage.
    Denial Risk

    Diagnosis and Off-Label Use Requirements

    Coverage criteria apply to Geographic Atrophy Secondary to Age-Related Macular Degeneration (GA-AMD). A condition not listed in the policy requires review to confirm medical necessity; for off-label use, the criteria in Health and Safety Code section 1367.21 must be met.

    • The request must meet the diagnosis requirement for GA-AMD.
    • If the requested condition differs from the covered indication, obtain medical-necessity review.
    • For use not approved by the Food and Drug Administration for the intended use, satisfy Health and Safety Code section 1367.21.
    Denial Risk

    Use Assigned Drug Codes

    Use the specific drug codes assigned to avacincaptad pegol (Izervay) in the drug policy. Do not use an unlisted, unspecified, or miscellaneous code when a specific code is assigned.

    • Submit the assigned HCPCS code and corresponding NDC.
    • Incorrect or nonspecific coding may result in claim rejection or denial.
    Mechanism noted in policyComplement C5 inhibitor