Payer PolicyActive
Syfovre (pegcetacoplan)
EVICORE-MEDICAL_DRUG-A8F55039
EviCore by Evernorth
Effective: July 1, 2023
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Syfovre (pegcetacoplan) is covered only for geographic atrophy (GA) secondary to age‑related macular degeneration (non‑GA indications excluded) when the patient has documented GA, a BCVA of 24 letters or better on ETDRS charts, and the injection is administered by or under the supervision of an ophthalmologist. Approval is for 12 months with required documentation of the planned dose/interval (15 mg intravitreal to each affected eye every 25–60 days) and adherence to applicable safety and coverage criteria.
Coverage Criteria Preview
Key requirements from the full policy
"Documentation of diagnosis: geographic atrophy secondary to age-related macular degeneration"
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