Avacincaptad Pegol (Izervay) — CPB 1041 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 1041 covering avacincaptad pegol (Izervay) for geographic atrophy secondary to age-related macular degeneration, effective September 26, 2025. Izervay is now a second-line therapy under Aetna's commercial plans — your team must document Syfovre failure, contraindication, or intolerance before billing HCPCS J2782 or expect a claim denial.

This is a step-therapy restriction that changes everything about how you build your prior authorization file. Aetna's Izervay coverage policy now explicitly names Syfovre (pegcetacoplan) as the preferred alternative. If your ophthalmology practice bills for Izervay as a first-line treatment under CPB 1041 Aetna, those claims will not get paid.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Avacincaptad Pegol (Izervay)
Policy Code	CPB 1041
Change Type	Modified
Effective Date	September 26, 2025
Impact Level	High
Specialties Affected	Ophthalmology
Key Action	Document Syfovre trial, contraindication, or intolerance before submitting prior auth for Izervay

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Aetna Izervay Coverage Criteria and Medical Necessity Requirements 2025

The coverage policy for Izervay under CPB 1041 has two distinct layers. First: Aetna covers Izervay for geographic atrophy (GA) secondary to age-related macular degeneration (AMD). Second — and this is the change that matters — Aetna now treats Izervay as medically necessary only when the member has a contraindication, intolerance, or an ineffective response to Syfovre.

Aetna's stated rationale is cost. The policy says directly that Izervay is more costly to Aetna than Syfovre, and that reliable evidence of Izervay's superiority does not exist. That's a payer making a formulary-style cost determination inside a medical benefit policy. Expect more of this pattern with other complement inhibitors.

Prior authorization is mandatory. Precertification is required for all Aetna participating providers in applicable plan designs. Call (866) 752-7021 for commercial plans or fax your Statement of Medical Necessity (SMN) form to (888) 267-3277. No prior authorization, no reimbursement — full stop.

For initial approval, the prescribing physician must be an ophthalmologist or work in consultation with one. Your PA submission needs to include the GA secondary to AMD diagnosis (ICD-10 codes from the H35.31xx family — more on those below) plus documentation of the Syfovre step-therapy requirement.

Continuation of therapy has its own standard. At reauthorization, you must show a positive clinical response. Aetna defines that as improvement or maintenance in best corrected visual acuity (BCVA), improvement or maintenance in visual field, a reduction in the rate of vision decline, or a reduction in the risk of more severe vision loss. Document any of those outcomes clearly in your reauth submission.

The dosing Aetna's policy references is 2 mg (0.1 mL of a 20 mg/mL solution) given by intravitreal injection once monthly — approximately every 28 ± 7 days. Each injection bills as CPT 67028 (intravitreal injection of a pharmacologic agent) paired with HCPCS J2782 (injection, avacincaptad pegol, 0.1 mg). Know your unit count: J2782 is billed per 0.1 mg, and the standard dose is 2 mg, so you're billing 20 units per eye per injection.

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Aetna Izervay Exclusions and Non-Covered Indications

Aetna draws a hard line on the underlying condition. Izervay is not covered for geographic atrophy secondary to anything other than AMD. That means GA caused by Stargardt disease, cone-rod dystrophy, or toxic maculopathies is explicitly excluded.

This matters for your ICD-10 selection. Do not use an H35.30 or H35.31xx code if the GA in your patient's chart traces back to one of those other conditions. Aetna will classify that claim as experimental, investigational, or unproven — and the denial will be correct.

All other indications beyond GA secondary to AMD are also considered experimental and investigational under this coverage policy. There is no off-label pathway here. If your prescriber is using Izervay for anything outside of GA secondary to AMD, do not expect Aetna coverage.

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Coverage Indications at a Glance

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Aetna Izervay Billing Guidelines and Action Items 2025

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Avacincaptad Pegol (Izervay) Under CPB 1041

Covered CPT Codes (When Selection Criteria Are Met)

Code	Type	Description Copy
67028	CPT	Intravitreal injection of a pharmacologic agent (separate procedure)

Covered HCPCS Codes (When Selection Criteria Are Met)

Code	Type	Description Copy
J2782	HCPCS	Injection, avacincaptad pegol, 0.1 mg

Key ICD-10-CM Diagnosis Codes

Aetna's policy lists 181 ICD-10-CM codes. The covered codes span nonexudative (dry) AMD with geographic atrophy. Below are the primary code families you'll encounter in practice:

The full list of 181 codes in the H35.30–H35.31xx range is available in CPB 1041 on Aetna's site. Your coders should reference the full code set and match laterality and stage to the clinical documentation precisely. Aetna's policy does not restrict by stage within the AMD/GA family — the coverage criteria focus on the drug selection logic, not the AMD staging code.

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What the Step-Therapy Requirement Really Means for Your Practice

This is the same pattern Aetna has used in other specialty drug categories — prefer one agent, require failure or intolerance before covering the other. The GA market is a two-drug market right now: Izervay (avacincaptad pegol) and Syfovre (pegcetacoplan). Aetna picked Syfovre as the preferred agent.

That's not a clinical judgment your practice gets to override without documentation. If your ophthalmologist has a clinical reason to start with Izervay — patient history, tolerability concerns, prior adverse reaction to Syfovre — that reasoning needs to be in the chart and in the PA submission. Vague notes won't cut it. Aetna will ask for specifics.

The real risk for Izervay billing is the claim denial pattern that follows a policy like this. If your team doesn't flag this change and continues submitting Izervay claims without step-therapy documentation, you'll see a surge in denials starting in late September 2025. Reversing those denials takes time you don't have.

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