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    v1.0.28
    OpenPayerPolicy UpdatesOphthalmology/OptometryCommunity-Care avacincaptad pegol Coverage Update …
    Ask Trek AI about this page
    CurrentCommunity-CarePolicy N/A

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

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    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
    Last ReviewMar 1, 2024
    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

    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.

    Mar 2024
    last 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.
    Continuation Approval: Patient continues to experience benefit based on the provider’s assessment and is appropriate to continue on therapy.

    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.

    This policy does not specify any items under “not medically necessary.” There are no documented scenarios in the policy text that define treatments or uses of avacincaptad pegol as not medically necessary for geographic atrophy secondary to age-related macular degeneration.

    When reviewing requests, follow the policy’s stated coverage criteria and quantity/authorization limits rather than assuming unspecified noncoverage conditions.

    Coding and Quantity Limits

    Applicable HCPCS CodesHCPCS
    J2782Injection, avacincaptad pegol, 0.1 mg
    inv-06: Quantity limit — key facts
    Quantity limitUp to 2 vials per 28 days (1 vial = 0.1 mL = 2 mg)
    Authorization periodIf approved, coverage is allowed for 1 year (subject to benefit changes)
    HCPCS code for drugJ2782 — Injection, avacincaptad pegol, 0.1 mg

    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.

    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.

    Definitions

    inv-12: Definition and coverage context
    Required diagnosisGeographic atrophy secondary to age-related macular degeneration (GA secondary to AMD)
    Prescriber requirementPrescribed by, or in consultation with, an ophthalmologist
    Continuation requirementFor continuation, patient must continue to experience benefit per provider assessment
    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
    Last ReviewMar 1, 2024
    Next Review DateMar 1, 2024
    Key ActionObtain prior authorization showing diagnosis of geographic atrophy secondary to AMD and ophthalmologist involvement.
    SourceLink
    On This Page
    Coverage Criteria for Avacincaptad pegolCoding and Quantity LimitsPrior Authorization & Documentation RequirementsBackgroundDefinitions
    Documentation Required

    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

    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