Ophthalmologic Complement Inhibitors – Commercial Medical Benefit Drug Policyopen_in_new

UnitedHealthcare covers avacincaptad pegol (Syfovre) and pegcetacoplan (Izervay) only for geographic atrophy (GA) secondary to age-related macular degeneration in adults and explicitly excludes macular atrophy from non‑AMD causes (e.g., Stargardt disease, cone‑rod dystrophy, toxic maculopathies) and off‑label use or other complement inhibitors unless required by member‑specific mandates. Coverage requires GA confirmation by GA‑sensitive testing (e.g., OCT/FAF), prescription/consultation by an ophthalmologist experienced in retinal disease, dosing per FDA labeling, documentation/billing per policy (including ICD‑10/HCPCS codes), initial/continuation authorizations limited to 12 months, and physician attestation plus documentation of titration to the minimum effective dosing frequency for long‑term use.

"Treatment of geographic atrophy (GA) secondary to age-related macular degeneration (AMD) (adult patients), using avacincaptad pegol (Syfovre) or pegcetacoplan (Izervay) when all coverage criteria a..."