Does J2781 require prior authorization?

Yes, J2781 requires prior authorization (high confidence). Code explicitly requires prior authorization.

What is the Medicare reimbursement rate for J2781?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

HCPCS/CPT

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Clinical documentation confirming diagnosis of geographic atrophy (GA) secondary to age-related macular degeneration (AMD).
Results of geographic atrophy sensitive tests confirming GA (examples given: optical coherence tomography [OCT], fundus autofluorescence [FAF] imaging).

Treatment of geographic atrophy (GA) secondary to age-related macular degeneration (AMD) (adult patients), using avacincaptad pegol (Syfovre) or pegcetacoplan (Izervay) when all coverage criteria are met.
Diagnosis of geographic atrophy (GA) secondary to age-related macular degeneration (AMD) confirmed by geographic atrophy sensitive tests (e.g., optical coherence tomography [OCT], fundus autofluorescence [FAF] imaging).
Use when prescribed by or in consultation with an ophthalmologist experienced in treatment of retinal diseases.
Use consistent with United States Food and Drug Administration approved labeling for the product (dosing and administration).
Initial therapy authorization may be granted for up to 12 months when criteria are met.
Continuation (maintenance/long-term) therapy when physician attests patient would benefit from continued administration and other continuation criteria are met (authorization up to 12 months).

ARKBLUE-PEGCETACOPLAN-INTRAVITREAL-E-G-SYFOVRE-5302ECCF61, Pegcetacoplan Intravitreal (e.g., Syfovre)

FLORIDA_BLUE-FLBLUE-PEGCETACOPLAN-SYFOVRETM-765110F925, Pegcetacoplan (Syfovre)

BCBSM-2171984-F25056E89C, SYFOVRE (PEGCETACOPLAN)

POINT32HEALTH-MDMNG-13906, Syfovre (pegcetacoplan injection)

MULTI

POINT32HEALTH-MDMNG-13916, Syfovre (pegcetacoplan injection)

MULTI

HEALTHNET_OR-HNOR-PEGCETACOPLAN-EMPAVELI-SYFOVRE-CP-PHAR-524-2F1F0FE212, Pegcetacoplan (Empaveli, Syfovre); CP.PHAR.524

MODA-SYFOVRE-EA403B90D2, Syfovre (pegcetacoplan)

EVICORE-MEDICAL_DRUG-01AC6CB055F2, Syfovre (pegcetacoplan injection)

UMR-POL-UMR-ophthalmologic-complement-inhibitors, Ophthalmologic Complement Inhibitors

SUREST-POL-SUREST-ophthalmologic-complement-inhibitors, Ophthalmologic Complement Inhibitors

BCBSTN-8060c8380e, Pegcetacoplan (Syfovre)

UHC-POL-ophthalmologic-complement-inhibitors, Ophthalmologic Complement Inhibitors

OSCAR-SYFOVRE-PEGCETACOPLAN-INJECTION-PG150-VER-4-D313B68DA5, Syfovre (pegcetacoplan injection) (PG150, Ver. 4)

Ask Backwork about documentation requirements, denial risks, or coverage in your state.