CurrentUnitedHealthcarePolicy CSIND00118.10

Ophthalmologic Complement Inhibitors (for Indiana Only)

State-specific UnitedHealthcare medical benefit drug policy governing coverage and clinical use of ophthalmologic complement inhibitors (avacincaptad pegol and pegcetacoplan) for members in Indiana.

Policy Summary

PayerUnitedHealthcare

PolicyOphthalmologic Complement Inhibitors (for Indiana Only)

Policy CodePolicy CSIND00118.10

Change TypeRoutine reviewno content changes

Effective DateDec 1, 2025

Next Review DateN/A

Key ActionFollow InterQual criteria when requesting prior authorization for J2781 and J2782.

SourceLink

POLICY UPDATE CHANGES

Routine review; no content changes

2ophthalmologic complement inhibitor products listed

Indianastate-specific applicability

J2781, J2782HCPCS codes referenced

H35.3113–H35.3134example ICD-10 codes

Coverage and Medical Necessity Criteria

Coverage per InterQual

Policy Summary

PayerUnitedHealthcare

PolicyOphthalmologic Complement Inhibitors (for Indiana Only)

Policy CodePolicy CSIND00118.10

Change TypeRoutine reviewno content changes

Effective DateDec 1, 2025

Next Review DateN/A

Key ActionFollow InterQual criteria when requesting prior authorization for J2781 and J2782.

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.

Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by federal, state, or contractual requirements and applicable laws and may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment; providers should confirm coverage under the member's benefit plan.

Relevant Codes

HCPCS drug codesHCPCS

J2781	Injection, pegcetacoplan, intravitreal, 1 mg.
J2782	Injection, avacincaptad pegol, 0.1 mg.

ICD-10 diagnosis codes (examples)ICD-10

H35.3113	Nonexudative age-related macular degeneration, right eye, advanced atrophic without subfoveal involvement.
H35.3114	Nonexudative age-related macular degeneration, right eye, advanced atrophic with subfoveal involvement.
H35.3123	Nonexudative age-related macular degeneration, left eye, advanced atrophic without subfoveal involvement.
H35.3124	Nonexudative age-related macular degeneration, left eye, advanced atrophic with subfoveal involvement.
H35.3133	Nonexudative age-related macular degeneration, bilateral, advanced atrophic without subfoveal involvement.
H35.3134	Nonexudative age-related macular degeneration, bilateral, advanced atrophic with subfoveal involvement.

Provider Requirements and Authorization

Prior Authorization

Prior Authorization Required (InterQual)

Prior authorization is guided by InterQual criteria. Coverage and medical necessity for avacincaptad pegol (Izervay) and pegcetacoplan (Syfovre) are determined per the current InterQual guideline; providers must follow InterQual-based prior authorization processes when requesting coverage.

Drugs covered under InterQual: Izervay (avacincaptad pegol); Syfovre (pegcetacoplan)

Note

Reference Plan Terms

Providers should reference federal, state, and contractual benefit plan requirements when deciding coverage. This policy is informational and does not override specific plan or regulatory requirements. In the event of a conflict between this policy and federal, state, or contractual plan terms, the applicable federal, state, or contractual requirements govern.

Check the member's specific plan for benefit coverage rules
If plan or law conflicts with this policy, follow the plan or law

Billing Rule

Coding Inclusion Is Not a Coverage Guarantee

Inclusion of procedure, diagnosis, or drug billing codes in this policy is for reference only and does not guarantee coverage or reimbursement. Benefit coverage and claim payment are determined by federal, state, or contractual requirements and applicable laws; other policies and guidelines may apply.

Code listings (e.g., J2781, J2782, ICD-10 H35.3113–H35.3134) are informational only
Listing a code does not imply coverage, reimbursement, or guarantee of payment

Background and Scope

This Indiana medical policy addresses ophthalmologic complement inhibitor therapies — specifically Izervay (avacincaptad pegol) and Syfovre (pegcetacoplan) — used to treat advanced atrophic (geographic atrophy) forms of nonexudative age-related macular degeneration. Coverage and medical necessity determinations for these products are made according to the current InterQual clinical criteria; providers seeking authorization for J2781 (pegcetacoplan, intravitreal, 1 mg) and J2782 (avacincaptad pegol, 0.1 mg) should follow InterQual requirements and submit the documentation specified therein.

Product Definitions

Izervay (avacincaptad pegol)

Generic nameavacincaptad pegol

Brand nameIzervay

Drug classOphthalmologic complement inhibitor

HCPCS codeJ2782 — Injection, avacincaptad pegol, 0.1 mg

Coverage determinationCovered when medical necessity is met per InterQual clinical criteria (see InterQual for specific eligibility and documentation requirements).

Syfovre (pegcetacoplan)

Generic namepegcetacoplan

Brand nameSyfovre

Drug classOphthalmologic complement inhibitor

HCPCS codeJ2781 — Injection, pegcetacoplan, intravitreal, 1 mg

Coverage determinationCovered when medical necessity is met per InterQual clinical criteria (see InterQual for specific eligibility and documentation requirements).