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ph-0721

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Izervay™ (avacincaptad pegol)

Policy Number: PH-0721

Intravitreal

Last Review Date: 05/02/2024

Date of Origin: 09/05/2023

Dates Reviewed: 09/2023, 05/2024

FOR PEEHIP Members Only -Coverage excludes the provider-administered medication(s) outlined in this drug policy from being accessed through a specialty pharmacy. It must be obtained through buy and bill.

  1. Length of Authorization

Coverage will be provided every 6 months and may be renewed for up to 12 months (i.e., 12 doses per each eye) of total therapy.

  1. Dosing Limits
  1. Quantity Limit (max daily dose) [NDC unit]:
  • Izervay 2 mg/0.1 mL solution for injection in a single-dose vial: 1 vial per eye every 28 days
  1. Max Units (per dose and over time) [HCPCS Unit]:
  • 40 billable units (4 mg) every 28 days up to 12 months

(Max units are based on administration to BOTH eyes)

  1. Initial Approval Criteria 1,2

Coverage is provided in the following conditions:

  • Patient must have an inadequate response, intolerance, or a contraindication to Syfovre; AND
  • Patient is at least 18 years of age; AND
  • Patient has a baseline assessment for all the following: best corrected visual acuity (BCVA), fundus autofluorescence (FAF) imaging, and optical coherence tomography (OCT); AND

Universal Criteria

  • Patient is free of ocular and/or peri-ocular infections; AND
  • Patient does not have active intraocular inflammation; AND
  • Will not be used in combination with other intravitreal complement inhibitor therapies (e.g. pegcetacoplan, etc); AND
  • Patient does not have category 5, or higher, visual impairment or blindness (i.e., no light perception-total blindness); AND

Geographic Atrophy (GA) † 1,2,3

  • The patient has a diagnosis of GA as defined by a phenotype of central geographic atrophy having 1 or more zones of well demarcated retinal pigmented epithelium (RPE) and/or choriocapillaris atrophy; AND
  • Disease is secondary to age-related macular degeneration (AMD); AND
  • Conditions other than AMD have been ruled out (e.g., Stargardt disease, cone rod dystrophy, toxic maculopathies, etc.)

FDA Approved Indication(s); Compendium recommended indication(s); Ф Orphan Drug

  1. Renewal Criteria 1,2

Coverage can be renewed based upon the following criteria:

  • Patient continues to meet the universal and indication-specific relevant criteria as identified in section III; AND
  • Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include: endophthalmitis, retinal detachment, neovascular (wet) AMD or choroidal neovascularization, increased intraocular pressure, etc. that cannot be adequately treated; AND
  • Patient has had disease stabilization or slowing of the rate of disease progression while on therapy compared to pre-treatment baseline as measured by any of the following:
    • Best corrected visual acuity (BCVA)
    • Fundus Autofluorescence (FAF)
    • Optical Coherence Tomography (OCT); AND
  • Continued administration is necessary for the maintenance treatment of the condition and the patient and provider have discussed potential decrease in frequency administrations; AND
  • Patient has not received a total of 12 months (i.e., 12 doses per each eye) of therapy
  1. Dosage/Administration 1

Indication

Dose

Geographic Atrophy

The recommended dose for 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.

  • Keep refrigerated. Prior to use, allow Izervay to reach room temperature, and may be kept at room temperature for up to 24 hours.
  • Each vial and syringe should only be used for the treatment of a single eye.
  1. Billing Code/Availability Information

HCPCS Code:

  • J2782 – Injection, avacincapted pegol, 0.1 mg; 1 billable unit = 0.1 mg

NDC:

  • Izervay 2 mg/0.1 mL solution for injection in a single-dose vial: 82829-0002-xx
  1. References
  1. Izervay [package insert]. Parsippany, NJ; Iveric bio, Inc.; February 2024. Accessed April 2024.
  2. Jaffe GJ, Westby K, Csaky KG, et al. C5 Inhibitor avacincaptad pegol for geographic atrophy due to age-related macular degeneration: a randomized pivotal phase 2/3 trial. Ophthalmology. 2021; 128: 576-586.
  3. American Academy of Ophthalmology-Preferred Practice Patterns (AAO-PPP) Retina/Vitreous Committee, Hoskins Center for Quality Eye Care. Age-Related Macular Degeneration PPP – Update 2019. Oct 2019.

Appendix 1 – Covered Diagnosis Codes

ICD-10

ICD-10 Description

H35.3113

Nonexudative age-related macular degeneration, right eye advanced atrophic without subfoveal involvement

H35.3114

Nonexudative age-related macular degeneration, right eye advanced atrophic with subfoveal involvement

H35.3123

Nonexudative age-related macular degeneration, left eye advanced atrophic without subfoveal involvement

H35.3124

Nonexudative age-related macular degeneration, left eye advanced atrophic with subfoveal involvement

H35.3133

Nonexudative age-related macular degeneration, bilateral eye advanced atrophic without subfoveal involvement

H35.3134

Nonexudative age-related macular degeneration, bilateral eye advanced atrophic with subfoveal involvement

H35.3193

Nonexudative age-related macular degeneration, unspecified eye advanced atrophic without subfoveal involvement

H35.3194

Nonexudative age-related macular degeneration, unspecified eye advanced atrophic with subfoveal involvement

Appendix 2 – Centers for Medicare and Medicaid Services (CMS)

The preceding information is intended for non-Medicare coverage determinations. Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs) may exist and compliance with these policies is required where applicable. Local Coverage Articles (LCAs) may also exist for claims payment purposes or to clarify benefit eligibility under Part B for drugs which may be self-administered. The following link may be used to search for NCD, LCD, or LCA documents https://www.cms.gov/medicare-coverage-database/search.aspx. Additional indications, including any preceding information, may be applied at the discretion of the health plan.

Medicare Part B Covered Diagnosis Codes (applicable to existing NCD/LCD/LCA):  N/A

Medicare Part B Administrative Contractor (MAC) Jurisdictions

Jurisdiction

Applicable State/US Territory

Contractor

E (1)

CA, HI, NV, AS, GU, CNMI

Noridian Healthcare Solutions, LLC

F (2 & 3)

AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ

Noridian Healthcare Solutions, LLC

5

KS, NE, IA, MO

Wisconsin Physicians Service Insurance Corp (WPS)

6

MN, WI, IL

National Government Services, Inc. (NGS)

H (4 & 7)

LA, AR, MS, TX, OK, CO, NM

Novitas Solutions, Inc.

8

MI, IN

Wisconsin Physicians Service Insurance Corp (WPS)

N (9)

FL, PR, VI

First Coast Service Options, Inc.

J (10)

TN, GA, AL

Palmetto GBA

M (11)

NC, SC, WV, VA (excluding below)

Palmetto GBA

L (12)

DE, MD, PA, NJ, DC (includes Arlington & Fairfax counties and the city of Alexandria in VA)

Novitas Solutions, Inc.

K (13 & 14)

NY, CT, MA, RI, VT, ME, NH

National Government Services, Inc. (NGS)

15

KY, OH

CGS Administrators, LLC