Humana: Izervay Payer Policy

Created by C. Denise Burrell, Modified on Tue, 25 Mar at 2:30 PM by C. Denise Burrell

Humana: Izervay Payer Policy (Beta Access)

TABLE OF CONTENTS

Line of Business
Precertification/Prior Authorization
Diagnoses and Criteria
- Geographic Atrophy (GA) Secondary to Age-Related Macular Degeneration (AMD)
Exclusions
Dosage and Administration
Additional Notes

Sources

HCPCS Code(s):	J2782
Precertification Required?	✅ Yes (Click Here for Full Policy)
Step Therapy Required?	Not Specified (Click Here for Full Policy)
Provider Fax Form:	To request the addition of this form to our database, please email us at Help@samacare.com, including a blank PDF version of the authorization form.
FDA Approved Indications:	Geographic Atrophy (GA)
Recommended Dosage:	2 mg (0.1 mL of 20 mg/mL solution) administered by intravitreal injection to each affected eye once monthly (approximately every 28 ± 7 days) for up to 12 months.

This policy outlines the coverage criteria for Izervay™, a complement inhibitor administered via intravitreal injection. It is indicated for the treatment of geographic atrophy (GA) secondary to age-related macular degeneration (AMD) and requires prior authorization for approval.

Line of Business

This policy applies to the following lines of business:

Medicare
Commercial

The effective date is September 27, 2023, with a revision date of August 28, 2024, and a review date of August 21, 2024.

Precertification/Prior Authorization

Required: Yes, prior authorization is required for all covered indications.

Diagnoses and Criteria

The member has a diagnosis of geographic atrophy secondary to age-related macular degeneration (AMD).
Izervay™ is prescribed by or in consultation with an ophthalmologist or retinal specialist.
The member has not previously received a total of 12 monthly doses of Izervay™ in the affected eye(s).
Approval Duration: Approval is for the plan year duration or as determined through clinical review.

Exclusions

Izervay™ is contraindicated in:
- Patients with ocular or periocular infections.
- Patients with active intraocular inflammation.
In clinical trials, Izervay™ use was associated with increased rates of neovascular AMD or choroidal neovascularization (7% in treated patients compared to 4% in the sham group by Month 12). Patients receiving Izervay™ should be monitored for signs of neovascular AMD.

Dosage and Administration

The recommended dose of Izervay™ is 2 mg (0.1 mL of 20 mg/mL solution) administered by intravitreal injection to each affected eye once monthly (approximately every 28 ± 7 days) for up to 12 months.

Additional Notes

Izervay™ binds to and inhibits complement protein C5, which prevents its cleavage to C5a and C5b, reducing the formation of the membrane attack complex (MAC).
Dosage limits beyond 12 months of treatment or for other uses are not specified in this policy.

Sources: https://mcp.humana.com/tad/tad_new/home.aspx?type=provider

⚠️ Disclaimer: This article is a policy summary and does not guarantee coverage or approval.

Policies may vary based on plan, payer-specific rules, state or regional requirements, benefit structure, formulary placement, and patient-specific considerations like diagnosis or clinical history. Always review the full policy and confirm details directly with the payer to ensure compliance.

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