C3 and C5 Complement Inhibitors
Defines medical necessity and site-of-service review criteria for C3 and C5 complement inhibitor drugs (e.g., pegcetacoplan, iptacopan, eculizumab, ravulizumab and others) across multiple indications including PNH, aHUS, gMG, NMOSD, and ANCA-associated vasculitis for Premera Blue Cross members.
Added coverage criteria for Piasky (crovalimab-akkz) for the treatment of certain individuals with paroxysmal nocturnal hemoglobinuria (PNH).
Updated confirmed granulocyte clone size to > 15% for Soliris, Ultomiris, and Empaveli for treatment of PNH.
Clarified that the medications listed are subject to the product's FDA dosage and administration prescribing information.
Added coverage for Zilbrysq (zilucoplan) for generalized myasthenia gravis (gMG) in adult individuals who are anti-AChR antibody positive.
Updated Empaveli, Fabhalta, and Piasky prior-therapy requirement language to require completion of at least 3 months of therapy with an eculizumab product.
Added coverage for Veopoz (pozelimab-bbfg) for treatment of CD55‑deficient protein‑losing enteropathy (CHAPLE disease).
Added coverage for Izervay (avacincaptad pegol) for geographic atrophy secondary to AMD and updated J3490 usage for Izervay.
Updated Soliris (eculizumab) myasthenia gravis indication from age ≥18 to age ≥6 years.
Clarified that Site of Service Medical Necessity criteria does not apply to Alaska fully‑insured members.
Changed requirement from completing 3 months of therapy with Soliris to completing 3 months with an eculizumab product for certain drugs (Empaveli, Fabhalta, Piasky).
Added coverage criteria for Piasky (crovalimab-akkz) for select PNH patients and added HCPCS code J3590 (later removed).
Added coverage for Zilbrysq (zilucoplan) for generalized myasthenia gravis (AChR antibody positive).
Added coverage for Bkemv (eculizumab-aeeb) and Epysqli (eculizumab-aagh) with new HCPCS codes Q5151 and Q5152.
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.