CurrentCignaPolicy N/A

Izervay (pegcetacoplan) prior authorization for intravitreal injection - Prior authorization form and requirements

Prior authorization form and requirements for requesting Izervay (pegcetacoplan) injections for Cigna members, targeting prescribers and facilities administering ophthalmic injections for age-related macular degeneration with geographic atrophy.

Policy Summary

PayerCigna

PolicyIzervay (pegcetacoplan) prior authorization for intravitreal injection

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form documenting diagnosis of geographic atrophy due to AMD, BCVA in the affected eye, whether new start or continuation, dose/frequency and J‑code, and prescriber attestation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time

Izervaymedication requested

20/25–20/320BCVA range queried

Accredopreferred specialty pharmacy

Coverage criteria and form items

Form completion / clinical information

Coverage assessment requires completion of the following information on the prior authorization form.

Form completion requirements: Provider must complete patient identifiers (Cigna ID, date of birth), prescriber identifiers (facility/doctor name, state, Tax ID, address; prescriber signature and date), medication details (Izervay 20 mg/mL, dose, frequency, J‑code), and indicate where medication will be obtained (eg, Accredo or other).

Information used to determine medical necessity; Accredo is Cigna's nationally preferred specialty pharmacy (NCPDP 4436920).

Therapy status and documentation: Indicate whether this is a new start or a continuation of therapy. If continuation, provide dates of prior use and documentation of beneficial response (Yes/No). If patient received samples, select 'new start'.

If continuation with no documented benefit, requestor should provide support for continued use.

Diagnosis and clinical measures:

Policy Summary

PayerCigna

PolicyIzervay (pegcetacoplan) prior authorization for intravitreal injection

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

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 submit and watch for

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Prior authorization is required for all starts and continuations of the requested medication. Submit a completed prior authorization form (electronic via CoverMyMeds or SureScripts, or paper/fax) including dose, frequency, form (e.g., injection), and whether this is a new start or a continuation. If patient has been taking samples, mark as a new start. Standard response time is 5 business days; call to request expedited/urgent review.

Include dose, frequency, formulation (e.g., 20 mg/mL solution for injection), and J-code when known
Indicate new start vs continuation; if samples were used, select new start
Submit electronically: www.covermymeds.com or via SureScripts in your EHR; or fax per form instructions

Documentation Required

Required Documentation on Form

Required documentation on the form: complete all administrative and clinical fields to avoid processing delays. Ensure patient and prescriber identifiers, diagnosis details, and supply/dispensing site information are provided.

Patient: full name, Cigna ID, date of birth, address, phone
Prescriber: physician name, specialty, DEA/NPI/TIN, office contact, phone and fax
Medication: medication name, dose, frequency, J-code (if available)
Treatment details: indication/diagnosis, whether ophthalmology involvement/consultation occurred
Dispensing/administration: facility or pharmacy selected (Accredo preferred specialty pharmacy), facility name, tax ID, address, and whether home infusion or in-office infusion will be used
Attestation: prescriber signature and date

Documentation Required

Continuation Documentation Required

Continuation-specific documentation: when requesting continuation of therapy, provide objective evidence of benefit and prior treatment dates. If continuation is requested but documentation of beneficial response is not present, include supportive clinical rationale and any outcome measures.

For continuation, indicate dates patient has been on the medication and how it was received (samples, out-of-pocket, office-administered)
Document evidence of beneficial response to therapy (clinical notes, vision measures, functional improvement) — check the continuation box and mark Yes for beneficial response when present
If no documented benefit, include supporting clinical justification for ongoing use
Include current best corrected visual acuity (BCVA) in affected eye when applicable and note if BCVA is between 20/25 and 20/320 letters

Key definitions and thresholds

inv-12: Geographic atrophy (GA) due to AMD

TermGeographic atrophy (GA) secondary to age-related macular degeneration

Form confirmationForm asks: 'Does the patient have geographic atrophy secondary to age-related macular degeneration?' with Yes/No checkboxes

PurposeIdentification of GA due to AMD is required on the form to support coverage assessment for Izervay injections

inv-13: BCVA threshold

BCVA thresholdBetween 20/25 and 20/320 letters in the affected eye

Form captureQuestion on the form: 'Does the patient have a best corrected visual acuity (BCVA) in the affected eye between 20/25 and 20/320 letters?' with Yes/No checkboxes

Impact on coverageFailure to document BCVA within this range may lead to denial of coverage during review

OpenPayer

Izervay (pegcetacoplan) prior authorization for intravitreal injection - Prior authorization form and requirements

Coverage criteria and form items

Codes, pharmacy and vision metrics

What providers must submit and watch for

Policy background

Key definitions and thresholds