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Avacincaptad Pegol (Izervay) (CPB 1041, reviewed 2025-06-06)
Effective date
Nov 13, 2023
Identified
Aug 12, 2026
Summary
This historical Aetna Clinical Policy Bulletin on Izervay (avacincaptad pegol), CPB 1041, was last reviewed 06/06/2025. For commercial medical plans, Aetna considers Izervay medically necessary only for members who have a contraindication, intolerance or ineffective response to Syfovre, and precertification is required in applicable plan designs. Aetna considers members not eligible for Izervay for geographic atrophy secondary to a condition other than age-related macular degeneration, such as Stargardt disease, cone-rod dystrophy or toxic maculopathies.
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What to do
Action · 3 steps
01Already effective 2023-11-13: Billing team: get precertification for Izervay in applicable plan designs by calling (866) 752-7021 for commercial members, or faxing (888) 267-3277.
02Confirm the prescriber is an ophthalmologist or is consulting with one.
03For commercial members, confirm a contraindication, intolerance or ineffective response to Syfovre before requesting Izervay.
Codes mentioned
J278267028H35.30
Original notice
Avacincaptad Pegol (Izervay) (CPB 1041, reviewed 2025-06-06)
aetna.com · Always check the source before changing claims.
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