Medicare AdvantagePrior AuthMedium impact
Syfovre® (pegcetacoplan) intravitreal solution (Revised)
Humana·KY, SC · Ophthalmology·Medicaid
Effective date
Dec 17, 2025
We identified it
Jun 25, 2026
Summary
Humana has revised its Syfovre (pegcetacoplan) intravitreal solution coverage policy effective December 17, 2025. This is a prior authorization requirement policy for the treatment of geographic atrophy secondary to age-related macular degeneration. The policy applies to Medicare, Medicaid-Kentucky, and Medicaid-South Carolina. Prior authorization is required; coverage is contingent on GA diagnosis secondary to AMD and prescription by or in consultation with an ophthalmologist or retinal specialist.
Action Required
By December 17, 2025: Billing and authorization teams must implement prior authorization procedures for Syfovre (pegcetacoplan) intravitreal injections across Medicare, Medicaid-Kentucky, and Medicaid-South Carolina plans. Update billing system workflows to flag all Syfovre claims for prior auth review before submission. Verify that claims include evidence of GA diagnosis secondary to AMD and that the prescribing provider is an ophthalmologist or retinal specialist. Add a clinical note requirement in the authorization template documenting specialist consultation per policy Criteria #2. Educate ophthalmology/retinal specialty providers about the two-part approval criteria. Route all prior auth requests to the appropriate Humana PAL (Preauthorization and Notification List) portal at www.humana.com/PAL for state-specific medical/procedural coding. Failure to obtain prior authorization will result in claim denials.