CurrentCareSource GeorgiaPolicy GA-MED-P-366579

Izervay (avacincaptad pegol) for Geographic Atrophy Secondary to Age-Related Macular Degeneration

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This policy governs CareSource Georgia Medicaid medical prior authorization coverage for intravitreal Izervay in members with geographic atrophy secondary to age-related macular degeneration. It establishes initial authorization, renewal, dosage, quantity, documentation, and medical-necessity requirements.

Policy Summary

PayerCareSource Georgia

PolicyIzervay (avacincaptad pegol) for Geographic Atrophy Secondary to Age-Related Macular Degeneration

Policy CodePolicy GA-MED-P-366579

Change TypeMaterial revision

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionSubmit medical prior authorization with required clinical documentation for Izervay.

SourceLink

POLICY UPDATE CHANGES

Renewal criteria were added for continued Izervay authorization.

The policy no longer limits Izervay treatment to a total duration of 12 months.

≥50 yearsMinimum member age

2.5–17.5 mm²Required total geographic atrophy area

20/25–20/320Required visual acuity range

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CurrentCareSource GeorgiaPolicy GA-MED-P-366579

Izervay (avacincaptad pegol) for Geographic Atrophy Secondary to Age-Related Macular Degeneration

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Policy Summary

PayerCareSource Georgia

PolicyIzervay (avacincaptad pegol) for Geographic Atrophy Secondary to Age-Related Macular Degeneration

Policy CodePolicy GA-MED-P-366579

Change TypeMaterial revision

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionSubmit medical prior authorization with required clinical documentation for Izervay.

SourceLink

POLICY UPDATE CHANGES

Renewal criteria were added for continued Izervay authorization.

The policy no longer limits Izervay treatment to a total duration of 12 months.

≥50 yearsMinimum member age

2.5–17.5 mm²Required total geographic atrophy area

20/25–20/320Required visual acuity range

12 monthsInitial authorization period

Additional 12 monthsRenewal authorization period

Coverage Criteria

Initial Therapy

Covered for initial authorization when all of the following are met.

Initial authorization

Member and prescriber requirements: The member is at least 50 years of age, and the medication is prescribed by or in consultation with an ophthalmologist.Age ≥50 years
Diagnosis and imaging
- Total geographic atrophy area is at least 2.5 mm² and no more than 17.5 mm² (1 to 7 disk areas, respectively).≥2.5 and ≤17.5 mm²
- Multifocal lesion, if applicable: If the geographic atrophy is multifocal, at least one focal lesion is at least 1.25 mm² (0.5 disk area).≥1.25 mm²
- Lesion location: The geographic atrophy lesion is partly within 1.5 mm of, but does not involve, the foveal center.Within 1.5 mm of, but not involving, the foveal center
Visual acuity: Best corrected visual acuity is between 20/25 and 20/320 in the affected eye or eyes.20/25–20/320
Disease exclusions: The geographic atrophy is not secondary to a condition other than age-related macular degeneration, and the member has no history of or current evidence of wet age-related macular degeneration.No alternative-cause geographic atrophy; no history or current evidence of wet AMD
Dose and quantity: Intravitreal injection is administered to each affected eye once monthly within the quantity limit.2 vials per 28 days

Continuation Therapy

Covered for reauthorization when the following criterion is met.

Continuation therapy: The geographic atrophy lesion growth rate has slowed or stabilized.Slowed or stabilized lesion growth rate

Coverage excludes geographic atrophy secondary to any condition other than age-related macular degeneration.

Coverage excludes members with a history of or current evidence of wet age-related macular degeneration.

Treatment of conditions or indications not listed in this policy is considered not medically necessary. Other indications should be evaluated under the applicable Off-Label policy.

Clinical and Quantity Parameters

Total geographic atrophy area

Minimum total area≥ 2.5 mm² (1 disk area)

Maximum total area≤ 17.5 mm² (7 disk areas)

Required rangeTotal geographic atrophy area must be ≥ 2.5 and ≤ 17.5 mm²

Multifocal geographic atrophy focal lesion

Applicable presentationMultifocal geographic atrophy

Minimum focal lesionAt least one focal lesion must be ≥ 1.25 mm²

Disk-area equivalent≥ 0.5 disk area

Authorization and Documentation Requirements

Prior Authorization

Medical Prior Authorization Required

Medical prior authorization is required for Izervay (avacincaptad pegol). Initial authorization is considered when the member meets the applicable age, prescriber, diagnosis, imaging, visual-acuity, and exclusion criteria.

Intravitreal injection is limited to each affected eye once monthly.
Quantity limit: 2 vials per 28 days.
If all initial requirements are met, approval is for 12 months.

Documentation Required

Initial Authorization Documentation

Submit documentation supporting the member's eligibility and clinical need for initial authorization, including member age, prescriber specialty or consultation, diagnosis, imaging findings, and visual acuity.

Member is at least 50 years of age.

Clinical Background

Izervay (avacincaptad pegol) is a complement C5 inhibitor approved for the treatment of geographic atrophy secondary to age-related macular degeneration.

Key Definitions

Dry age-related macular degeneration

Type of AMDA form of age-related macular degeneration

ProgressionMore common than wet AMD and progresses more slowly to vision loss

Potential progressionMay advance to geographic atrophy

Wet age-related macular degeneration

DefinitionAge-related macular degeneration involving new blood vessel growth

Clinical descriptionAlso called wet or neovascular AMD

Policy exclusionMembers with a history of or current evidence of wet AMD are excluded from initial coverage

Policy Summary

PayerCareSource Georgia

PolicyIzervay (avacincaptad pegol) for Geographic Atrophy Secondary to Age-Related Macular Degeneration

Policy CodePolicy GA-MED-P-366579

Change TypeMaterial revision

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionSubmit medical prior authorization with required clinical documentation for Izervay.

SourceLink

On This Page

Lesion location

Distance from foveal centerWithin 1.5 mm of the foveal center

Lesion relationshipThe lesion must be, in part, within the specified distance

Foveal center involvementMust not involve the foveal center

Best corrected visual acuity

Affected eye(s)Visual acuity must be documented for the affected eye or eyes

Best corrected visual acuity rangeBetween 20/25 and 20/320

Lower threshold20/25

Upper threshold20/320

Quantity limit

Vial limit2 vials

Dispensing periodPer 28 days

Administration scheduleIntravitreal injection to each affected eye once monthly

Medication is prescribed by or in consultation with an ophthalmologist.

Documented diagnosis of geographic atrophy secondary to age-related macular degeneration.

Fundus autofluorescence (FAF) imaging confirms: total GA area of 2.5–17.5 mm² (1–7 disk areas); for multifocal GA, at least one focal lesion of at least 1.25 mm² (0.5 disk area); and the lesion is partly within 1.5 mm of, but does not involve, the foveal center.

Best corrected visual acuity (BCVA) is documented between 20/25 and 20/320 in the affected eye(s).

Documentation Required

Renewal Documentation

For reauthorization, documentation must show that the geographic atrophy lesion growth rate has slowed or stabilized. When this requirement is met, approval may be extended for an additional 12 months.

Denial Risk

Initial Clinical Criteria Not Met

Initial authorization may be denied when the member does not meet the required clinical criteria, including the minimum age, ophthalmologist prescribing or consultation requirement, imaging findings, lesion location or size, or BCVA range.

Member is younger than 50 years of age.
Medication is not prescribed by or in consultation with an ophthalmologist.
Required diagnosis, FAF findings, lesion measurements/location, or BCVA documentation is missing or does not meet policy requirements.

Denial Risk

Non-Covered Disease Presentation

Coverage may be denied when the disease presentation is not the covered indication of geographic atrophy secondary to age-related macular degeneration.

GA is secondary to a condition other than AMD.
The member has a history of or current evidence of wet (neovascular) AMD.

Denial Risk

Renewal Response Not Demonstrated

Reauthorization may be denied when documentation does not demonstrate that the geographic atrophy lesion growth rate has slowed or stabilized.

Denial Risk

Unlisted Indication

Izervay is not medically necessary for conditions or indications not listed in this policy. For any other indication, evaluate coverage under the Off-Label policy.

Geographic atrophy

Underlying processBreakdown of cells in the macula

Lesion characteristicResults in irreversible lesions

Potential impactLesions can impair vision or lead to blindness