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AetnaCommercial · Prior Auth · Pharmacy · Ophthalmology, PharmacyLow impact

Pegcetacoplan Intravitreal Injection (Syfovre) (CPB 1029, reviewed 2026-04-09)

Effective date
Not stated in the notice
Identified
Aug 13, 2026

Summary

Aetna reviewed its clinical policy bulletin 1029 on 04/09/2026 for Syfovre (pegcetacoplan) intravitreal injections, which Aetna covers for commercial plans only when the patient has geographic atrophy secondary to age-related macular degeneration and the drug is prescribed by or with an ophthalmologist. The text does not identify what changed in the review, and the policy history shows an original 07/01/2023 effective date, so treat this as a reminder of current criteria and confirm the live Aetna version before relying on it. Precertification is required for applicable plans, and Aetna does not consider the drug eligible for geographic atrophy caused by conditions other than AMD.

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What to do

Action · 7 steps
01No source-stated future deadline.
02Ophthalmology billing and the prior authorization team: for commercial Aetna members on Syfovre, obtain Aetna precertification before scheduling the injection by calling (866) 752-7021 or faxing (888) 267-3277, using the Statement of Medical Necessity form where needed, and record the approval in the prior authorization tracker.
03Confirm the chart documents geographic atrophy secondary to AMD and that the drug is ordered by or in consultation with an ophthalmologist.
04Tell providers and front desk staff that Aetna considers Syfovre not eligible for geographic atrophy caused by other conditions such as Stargardt disease, cone rod dystrophy, or toxic maculopathies.
05For continuation requests, document a positive clinical response (a stabilized or slower decline in vision, or stabilized or reduced GA lesion area) in the chart.
06Charge entry for the injection should use J2781 with 67028 where the source lists them.
07For Medicare members, Aetna points to a separate Medicare Part B criteria document, which this bulletin does not cover.

Codes mentioned

67028J2781H35.30

Original notice

Pegcetacoplan Intravitreal Injection (Syfovre) (CPB 1029, reviewed 2026-04-09)
aetna.com · Always check the source before changing claims.
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Related policy hubs

Aetna policiesOphthalmologyPharmacyCode 67028Code J2781Code H35.30

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