CurrentCommunity-CarePolicy N/A

Avacincaptad pegol (J2782) — medical benefit coverage criteria for geographic atrophy (age-related macular degeneration)

Defines medical benefit coverage criteria, quantity limits, and authorization period for avacincaptad pegol to treat geographic atrophy secondary to age-related macular degeneration for members under the payer's medical benefit.

Policy Summary

PayerCommunity-Care

PolicyAvacincaptad pegol for geographic atrophy (age-related macular degeneration) — coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateMar 1, 2024

Key ActionObtain prior authorization showing diagnosis of geographic atrophy secondary to AMD and ophthalmologist involvement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 yrauthorization period

2 vials/28dmax quantity

J2782HCPCS

Mar 2024last reviewed

Coverage Criteria for Avacincaptad pegol

Initial Approval

Covered when ALL of the following are met for initial approval:

Initial Approval: Prescribed by, or in consultation with, an ophthalmologist.

Initial Approval: Diagnosis of geographic atrophy secondary to age-related macular degeneration.

Continuation Therapy

Covered when ALL of the following are met for continuation:

Continuation Approval: Diagnosis of geographic atrophy secondary to age-related macular degeneration.

Policy Summary

PayerCommunity-Care

PolicyAvacincaptad pegol for geographic atrophy (age-related macular degeneration) — coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateMar 1, 2024

Key ActionObtain prior authorization showing diagnosis of geographic atrophy secondary to AMD and ophthalmologist involvement.

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.

None explicitly listed in this policy document for additional coverage criteria beyond the stated initial and continuation requirements. The policy’s coverage determination sections specify only the prerequisites for initial approval and continuation of therapy (diagnosis of geographic atrophy secondary to age-related macular degeneration and involvement of an ophthalmologist for initial requests), and do not enumerate any other eligibility conditions or exclusions.

For operational clarity, rely on the explicit requirements in the Coverage Determination sections when evaluating requests; do not impose additional criteria that are not documented in the policy.

Prior Authorization & Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for avacincaptad pegol. Requests must be submitted and approved before dispensing or administration.

Drug: avacincaptad pegol
If approved, authorizes up to 2 vials per 28 days (1 vial = 0.1 mL = 2 mg)
Authorization period: up to 1 year (subject to benefit changes)

Note

Provider Action

Prescribers should verify prior authorization approval and follow any authorization limits. Ensure the treating provider information and ophthalmology involvement are clearly documented.

Documentation Required

Documentation must include a confirmed diagnosis of geographic atrophy (GA) secondary to age-related macular degeneration (AMD) and evidence that the medication was prescribed by, or in consultation with, an ophthalmologist.

Diagnosis: geographic atrophy secondary to age-related macular degeneration (GA secondary to AMD)
Prescriber: ophthalmologist or documented consultation with an ophthalmologist

Denial Risk

Requests lacking required documentation (diagnosis of GA secondary to AMD, ophthalmologist involvement, or evidence of medical necessity/benefit for continuation) or not prescribed by an appropriate provider should be denied.

Missing diagnosis of GA secondary to AMD
No documentation of ophthalmologist prescriber or consultation
Insufficient evidence of benefit for continuation requests

Background

Geographic atrophy (GA) is an advanced form of age-related macular degeneration (AMD) that results in progressive loss of retinal tissue and vision. Intravitreal therapies such as avacincaptad pegol are used in this context to slow disease progression. The policy requires that therapy be for GA secondary to AMD and that initial prescriptions be made by, or in consultation with, an ophthalmologist.

For continuity of care, the policy permits continuation of therapy when the diagnosis of GA secondary to AMD is confirmed and the patient is assessed by the provider to be deriving benefit and is appropriate to continue treatment. Quantity and authorization limits apply if approved.

OpenPayer

Avacincaptad pegol (J2782) — medical benefit coverage criteria for geographic atrophy (age-related macular degeneration)

Coverage Criteria for Avacincaptad pegol

Coding and Quantity Limits

Prior Authorization & Documentation Requirements

Background

Definitions