CurrentUnitedHealthcarePolicy CSLA2025D00118E

Ophthalmologic Complement Inhibitors (for Louisiana Only)

Defines medical benefit drug coverage criteria for avacincaptad pegol and pegcetacoplan for treatment of geographic atrophy secondary to age-related macular degeneration for UnitedHealthcare Community Plan — Louisiana only.

Policy Summary

PayerUnitedHealthcare

PolicyOphthalmologic Complement Inhibitors (for Louisiana Only)

Policy CodePolicy CSLA2025D00118E

Change TypeNon-material reference updates

Effective DateDec 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization with documentation of diagnosis, diagnostic test confirmation (e.g., OCT or FAF), prescribing clinician specialty, and dosing per FDA labeling.

SourceLink

POLICY UPDATE CHANGES

Updated References section to reflect the most current information; archived previous policy version CSLA2024D00118D.

12 monthsmax authorization

J2781, J2782HCPCS codes

H35.3113–H35.3134ICD-10 codes

Louisianaapplies to

Avacincaptad pegol, pegcetacoplandesignated agents

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Coverage Criteria

Initial Therapy

Covered when ALL of the following are met

Initial therapy: Diagnosis of geographic atrophy (GA) secondary to age-related macular degeneration (AMD); diagnosis confirmed by GA-sensitive tests (e.g., optical coherence tomography [OCT], fundus autofluorescence [FAF]); macular atrophy is not secondary to other conditions (e.g., Stargardt disease, cone rod dystrophy, toxic maculopathies); prescribed by or in consultation with an ophthalmologist experienced in treatment of retinal diseases; dosing in accordance with United States Food and Drug Administration approved labeling; authorization for no more than 12 months.

Continuation Therapy

Covered when ALL of the following are met

Continuation therapy: Physician attestation that the patient would benefit from continued administration; for long-term treatment, documentation of titration to the minimum effective dose and frequency needed to maintain a sustained clinical response; dosing in accordance with United States Food and Drug Administration approved labeling; authorization for no more than 12 months.

Macular atrophy that is secondary to conditions other than age-related macular degeneration (AMD) is excluded from coverage under this policy. Examples of excluded etiologies include Stargardt disease, cone-rod dystrophy, and toxic maculopathies. Coverage is specific to macular atrophy when it is documented as secondary to AMD and meets the other listed diagnostic and prescribing criteria.

Use of Izervay or Syfovre for macular atrophy that is not secondary to AMD, or when the required diagnostic confirmation is not provided, does not meet the specified coverage criteria and would be considered not medically necessary. Prior authorization requests must include documentation confirming the diagnosis of GA secondary to AMD with GA-sensitive testing (for example, OCT or FAF), appropriate diagnosis coding, and evidence that dosing and prescribing clinician meet policy requirements.

Coding and Authorization Limits

Covered HCPCS Drug CodesHCPCSCovered

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

Diagnosis Codes (ICD-10)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.

Authorization duration

Authorization durationAuthorization is for no more than 12 months (initial and continuation therapy)

Renewal frequencyAuthorization may be granted up to 12 months per request; continuation requires physician attestation of benefit

Dosing complianceAuthorization contingent on dosing in accordance with FDA‑approved labeling

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Include clear documentation of the GA diagnosis, diagnostic testing that confirms GA (e.g., OCT, FAF), the prescribing clinician's specialty (ophthalmologist experienced in retinal disease), and that requested dosing aligns with FDA-approved labeling. Requests for authorization exceeding 12 months or dosing outside FDA labeling risk denial.

Affected HCPCS: J2781, J2782
Affected ICD-10 examples: H35.3113, H35.3114, H35.3123, H35.3124, H35.3133, H35.3134

Documentation Required

Required Documentation

Providers must: obtain and submit diagnostic imaging confirming GA (e.g., OCT and FAF), document macular involvement and that GA is due to AMD (not other macular diseases), include ophthalmology consultation or that the prescriber is experienced in retinal disease, and attest to dosing consistent with FDA labeling. For continuation requests, include physician attestation of clinical benefit and documentation of dose/frequency titration to the minimum effective regimen for long-term treatment.

Background

Geographic atrophy (GA) is an advanced form of nonexudative AMD characterized by progressive loss of retinal tissue and expansion of atrophic lesions. The policy recognizes GA as a distinct diagnosis that must be confirmed with GA-sensitive imaging (for example, optical coherence tomography (OCT) or fundus autofluorescence (FAF)) and treated only when secondary to AMD because treatment benefit and indications in other macular atrophy etiologies differ.

Definitions

Geographic atrophy (GA) — definition

DefinitionGeographic atrophy (GA): an advanced form of dry age‑related macular degeneration characterized by progressive, irreversible retinal cell loss and lesion expansion that leads to permanent visual acuity loss.

Typical courseTypically begins in the parafoveal region and expands to involve the fovea over time, causing vision loss.

PathophysiologyLesion growth is driven in part by excessive complement activation (notably complement C3).

Complement inhibitors (avacincaptad pegol, pegcetacoplan)

AgentsAvacincaptad pegol (intravitreal) and pegcetacoplan (intravitreal)

IndicationProven for treatment of geographic atrophy (GA) secondary to age‑related macular degeneration (AMD) based on randomized controlled trials showing reduced GA lesion growth.

Policy Scope & Key Metrics

LouisianaState applicability

2Agents listed (avacincaptad pegol, pegcetacoplan)

J2781,J2782HCPCS drug codes required on requests

12 monthsMaximum authorization period