Pegcetacoplan Intravitreal Injection (Syfovre) — CPB 1029 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 1029 covering pegcetacoplan (Syfovre) intravitreal injections, effective September 26, 2025. Here's what billing teams need to do.

Aetna updated its pegcetacoplan coverage policy under CPB 1029 Aetna system, affecting HCPCS code J2781 (1 mg injection) and CPT code 67028 (intravitreal injection) for geographic atrophy secondary to age-related macular degeneration. This is a commercial plan policy — Medicare patients follow a separate path. If your ophthalmology or retina practice bills Syfovre for Aetna members, this update directly affects your prior authorization workflow and your claim submission requirements.

Quick-Reference Table

Aetna Pegcetacoplan Coverage Criteria and Medical Necessity Requirements 2025

The core of the Aetna pegcetacoplan coverage policy is this: precertification is required. Every time. For every Aetna participating provider and every member on an applicable commercial plan design.

Syfovre (pegcetacoplan) is a complement inhibitor delivered by intravitreal injection — billed under HCPCS J2781 at 1 mg per injection and procedure code CPT 67028. Aetna covers J2781 when medical necessity criteria are met, but "when criteria are met" only matters if you've cleared precertification first. A claim without prior authorization is a denied claim, regardless of how well-documented the medical necessity is.

The covered indication is geographic atrophy (GA) secondary to age-related macular degeneration (AMD). The ICD-10-CM codes that support this are in the H35.30–H35.31xx range, covering unspecified macular degeneration and the full spectrum of nonexudative AMD with GA. Aetna's policy lists over 170 diagnosis codes in this range — which signals they want very specific laterality and staging documentation. More on that under the code section below.

For Medicare-covered patients, do not use CPB 1029. Aetna directs Medicare criteria to their Part B step policy. If your practice sees a mix of commercial and Medicare Aetna members, your billing team needs separate workflows for each. Conflating the two is one of the fastest ways to generate a claim denial.

To get precertification for Syfovre under Aetna commercial plans, call (866) 752-7021 or fax (888) 267-3277. For a Statement of Medical Necessity form, go to Aetna's Specialty Pharmacy Precertification page. Have the SMN completed before the injection date — not after.

Reimbursement for pegcetacoplan billing flows through the medical benefit, not pharmacy. That means your billing team owns the J2781 and 67028 claim, not your pharmacy team. Make sure charge capture routes these codes correctly.

Coverage Indications at a Glance

Aetna Pegcetacoplan Billing Guidelines and Action Items 2025

This policy is effective September 26, 2025. If you're billing Syfovre injections to Aetna commercial plans right now, these are the steps to take.

If your practice does high Syfovre volume and you're not sure how this modified policy interacts with your existing Aetna contract terms, talk to your compliance officer or billing consultant before the effective date.

CPT, HCPCS, and ICD-10 Codes for Pegcetacoplan Intravitreal Injection Under CPB 1029

Covered HCPCS Codes (When Selection Criteria Are Met)

Key ICD-10-CM Diagnosis Codes

Aetna's CPB 1029 lists over 170 ICD-10-CM codes, all within the geographic atrophy / nonexudative AMD range. The table below includes all codes provided in the policy data. The H35.311x–H35.318x series encodes staging and laterality in granular detail — the last two digits drive much of the specificity.

The policy data provided includes 80 of the 170+ covered ICD-10-CM codes. The full list is available in the source policy at CPB 1029 on the Aetna provider portal. Review the complete list to confirm your documentation supports the most specific code before submitting.

A note on the ICD-10 volume: 170 codes for a single drug is a lot. The real message here is that Aetna wants granular documentation of which eye, which stage, and which subtype of nonexudative AMD is present. H35.30 — the catch-all "unspecified macular degeneration" code — is in the list. But if your retina specialist has documented staging and laterality in the chart, you should be coding to that level of detail. Using H35.30 when a more specific code is available is a soft target for a medical necessity challenge on continued therapy.