CurrentCignaPolicy N/A

Ophthalmology - Izervay

Defines Cigna's prior authorization, coverage criteria, dosing limits, and exclusions for Izervay for treatment of geographic atrophy secondary to age-related macular degeneration for affected members and providers.

Policy Summary

PayerCigna

PolicyOphthalmology - Izervay

Policy CodePolicy N/A

Change TypeTitle updatecoding removalsnew exclusion

Effective Date

Next Review Date

Key ActionObtain prior authorization; approvals are issued for 1 year when all clinical criteria are met.

SourceLink

POLICY UPDATE CHANGES

Policy title updated from 'Avacincaptad Intravitreal Injection' to 'Ophthalmology - Izervay.'

Deleted codes C9399, J3490, J3590 from coding.

Condition not recommended for approval: Concomitant use with Syfovre (pegcetacoplan intravitreal injection).

1 yearinitial approval duration

2 mgapproved dose per eye

monthlydosing interval

20/25–20/320BCVA eligibility

J2782primary code

Coverage Criteria for Izervay (avacincaptad pegol)

FDA-Approved Indication — Geographic Atrophy

Approve for 1 year if the patient meets ALL of the following (A, B, and C):

Initial approval for Geographic Atrophy

A) Patient has geographic atrophy secondary to age-related macular degeneration;required
B) Patient has a best corrected visual acuity (BCVA) in the affected eye of between 20/25 and 20/320 letters;required
C) The medication is administered by or under the supervision of an ophthalmologist.required

Policy Summary

PayerCigna

PolicyOphthalmology - Izervay

Policy CodePolicy N/A

Change TypeTitle updatecoding removalsnew exclusion

Effective Date

Next Review Date

Key ActionObtain prior authorization; approvals are issued for 1 year when all clinical criteria are met.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

What Providers Must Do

Prior Authorization

Prior Authorization Required

Prior Authorization is required for Izervay. Approvals are issued for 1 year when all clinical criteria are met. Because of the specialized skills required for evaluation and diagnosis and monitoring for adverse events and long-term efficacy, Izervay must be prescribed by or in consultation with a physician who specializes in the condition being treated (e.g., ophthalmologist).

Prior auth approval duration: 1 year
Prescriber requirement: prescribed by or in consultation with a specialist in the treated condition (ophthalmologist)
Administration requirement: medication must be administered by or under the supervision of an ophthalmologist

Step Therapy

Step Therapy / Concomitant Agent

No step therapy is specified for Izervay. Concomitant use with Syfovre (pegcetacoplan intravitreal injection) is explicitly not recommended and is considered not medically necessary due to lack of supporting data.

Step therapy: none specified
Concomitant agent: Concomitant use with Syfovre is not recommended / not medically necessary

Documentation Required

Prescriber and Clinical Documentation Required

Documentation must demonstrate that the patient meets the FDA-approved indication and dosing criteria for geographic atrophy secondary to age-related macular degeneration, including visual acuity and dosing interval requirements. Include documentation of specialist involvement (prescribing or consultation) and that administration will occur under ophthalmologist supervision.

Indication documentation: geographic atrophy secondary to AMD
Visual acuity documentation: BCVA between 20/25 and 20/320 in the affected eye
Dosing documentation: 2 mg (0.1 mL of 20 mg/mL) intravitreal injection per eye; interval not more frequent than every 21 days (typical ~28 ± 7 days)
Specialist documentation: name and specialty of prescribing/consulting physician (ophthalmologist)
Administration documentation: confirmation medication will be administered by or under supervision of an ophthalmologist

Billing Rule

Coding and Billing Denials

Claims lacking covered or active codes will be denied. Use current, appropriate codes when billing; deleted or inactive codes at time of service may not be eligible for reimbursement.

Covered HCPCS code when criteria met: J2782 — Injection, avacincaptad pegol, 0.1 mg
Do not bill with deleted or inactive codes; such claims may be denied

Denial Risk

Prior Authorization Reminder

Reinforces that prior authorization is required and approvals are for 1 year when all clinical criteria are satisfied. Services provided without required authorization may be denied.

Prior authorization required — risk of denial without authorization
Authorization duration: 1 year when criteria are met

Background

Geographic atrophy (GA) is an advanced, non‑neovascular form of age‑related macular degeneration characterized by localized outer retinal and retinal pigment epithelium atrophy with irreversible photoreceptor loss, leading to progressive and permanent central vision impairment. Izervay (avacincaptad pegol) is a complement C5 inhibitor indicated to treat GA secondary to AMD; clinical trial enrollment and the coverage criteria reference a treated‑eye best corrected visual acuity (BCVA) range of 20/25 to 20/320, with the recommended dose being 2 mg intravitreal injection once monthly (administration details and supervision requirements are specified in the coverage criteria).

Definitions

Geographic atrophy (GA) — definition and key clinical descriptors

DefinitionGeographic atrophy (GA): an advanced form of non‑neovascular age‑related macular degeneration (AMD) characterized by localized atrophy of outer retinal tissue with irreversible loss of photoreceptors, retinal pigment epithelium, and choriocapillaris.

Clinical significanceGA involving the foveal center contributes substantially to severe vision loss and accounts for ~10% of AMD‑related vision loss to 20/200 or worse.

Typical visual acuity range in clinical trialsBest‑corrected visual acuity (BCVA) eligibility in trials: 20/25 to 20/320 in the affected eye.

Pathophysiology noteGA is the advanced, non‑neovascular form of AMD (distinct from neovascular/wet AMD) marked by progressive, localized outer retinal atrophy.

Therapeutic contextIzervay (avacincaptad pegol), a complement C5 inhibitor, is indicated for treatment of GA secondary to AMD and was studied in patients meeting the BCVA range above.

C9399	Removed (previously listed)
J3490	Removed (previously listed)
J3590	Removed (previously listed)