Does J2782 require prior authorization?

Yes, J2782 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J2782?

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

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`J2782`, Injection, avacincaptad pegol, 0.1 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

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).

Key Coverage Criteria

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).

17 Active Policies

ARKBLUE-AVACINCAPTAD-PEGOL-E-G-IZERVAY-39F2B948D7, Avacincaptad pegol (e.g., Izervay)

BCBSM-2177235-91B069B8D0, IZERVAY (AVACINCAPTAD PEGOL)

POINT32HEALTH-MDMNG-13031, Izervay (avacincaptad pegol)

MULTI

POINT32HEALTH-MDMNG-13021, Izervay (avacincaptad pegol)

MULTI

HEALTHNET_OR-HNOR-AVACINCAPTAD-PEGOL-IZERVAY-CP-PHAR-641-8CCB1E65EB, Avacincaptad pegol (Izervay); CP.PHAR.641

MODA-IZERVAY-325DA09AAB, Izervay (avacincaptad pegol)

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

BCBSMT-OTH903.045, Avacincaptad pegol

BCBSIL-OTH903.045, Avacincaptad pegol

BCBSTN-47f159f55e, Avacincaptad Pegol (Izervay)

EVICORE-MEDICAL_DRUG-4BF39CD58954, Izervay (avacincaptad pegol intravitreal solution)

OSCAR-IZERVAY-AVANCINCAPTAD-PEGOL-PG168-VER-3-A411A01CE6, Izervay (avancincaptad pegol) (PG168, Ver. 3)

OSCAR-IZERVAY-AVANCINCAPTAD-PEGOL-PG168-VER-4-1AFA16AEFD, Izervay (avancincaptad pegol) (PG168, Ver. 4)

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

BCBSOK-OTH903.045, Avacincaptad pegol

BCBSNM-OTH903.045, Avacincaptad pegol

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

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J2782, Injection, avacincaptad pegol, 0.1 mg