Syfovre and Izervay must not be used with other geographic atrophy drugs for commercial members

For dates of service on or after Nov. 24, 2023, the following drugs must not be used in combination with each other or any other geographic atrophy, or GA, drug:

• Syfovre^® (pegcetacoplan), HCPCS codes J3490 and C9151
• Izervay™ (avacincaptad pegol), HCPCS code J3590

This change affects Blue Cross Blue Shield of Michigan commercial members and Blue Care Network commercial members.

Syfovre and Izervay will continue to require prior authorization through NovoLogix^®, as specified in the Blue Cross and BCN utilization management medical drug list for Blue Cross commercial and BCN commercial members.

Some Blue Cross commercial groups not subject to these requirements

For Blue Cross commercial groups, this authorization requirement applies only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list.

Note: Blue Cross and Blue Shield Federal Employee Program^® members and UAW Retiree Medical Benefits Trust (non-Medicare) members don’t participate in the standard prior authorization program.

Additional information

For additional information about drugs covered under the medical benefit, see the following pages of the ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

Prior authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.