Medicare AdvantagePrior AuthMedium impact
Izervay™ (avacincaptad pegol) (Revised)
Humana·KY, SC · Ophthalmology·Medicaid
Effective date
Dec 17, 2025
We identified it
Jun 25, 2026
Summary
Humana has updated its prior authorization policy for Izervay™ (avacincaptad pegol), a complement inhibitor intravitreal injection for geographic atrophy secondary to age-related macular degeneration. The revised policy (effective December 17, 2025) requires prior authorization for Medicare and Medicaid members in Kentucky and South Carolina, with approval based on GA diagnosis and prescription by an ophthalmologist or retinal specialist. Billing teams must implement prior auth requirements and ensure provider specialty verification before claim submission.
Action Required
By December 17, 2025: Billing team must implement prior authorization requirement for all Izervay (avacincaptad pegol) intravitreal solution claims for Medicare and Medicaid members in Kentucky and South Carolina. Verify that prescribing provider is an ophthalmologist or retinal specialist before submitting claims. Add prior auth requirement to billing system and update claim scrubbing rules to flag any Izervay prescriptions lacking PA documentation. Front desk staff should communicate prior auth requirement to referring providers. For medically billed requests, direct providers to www.humana.com/PAL for applicable procedure coding information. Claims submitted without prior authorization will be denied. Educate clinical staff that patients with developed choroidal neovascularization may require concomitant anti-VEGF therapy monitoring.