Pharmacy Prior Authorization Criteria

Syfovre (pegcetacoplan)

Indications for Prior Authorization

Syfovre (pegcetacoplan)

• For diagnosis of Geographic Atrophy (GA)
  Indicated for the treatment of geographic atrophy (GA) secondary to age-related macular degeneration (AMD).

Criteria

Syfovre

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of geographic atrophy (GA) secondary to age-related macular degeneration (AMD) as confirmed by one of the following:
• Fundus photography (e.g. fundus autofluorescence [FAF])
• Optical coherence tomography (OCT)
• Fluorescein angiography
AND
• Prescribed by or in consultation with an ophthalmologist experienced in the treatment of retinal diseases

Syfovre

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy (e.g., reduction in growth rate of GA lesion)

P & T Revisions

2024-06-18, 2024-03-13, 2023-10-16, 2023-06-16, 2023-04-14

References

1. Syfovre Prescribing Information. Apellis Pharmaceuticals, Inc. Waltham, MA. November 2023.

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Revision History

• 2024-06-18: Removed criterion "GA is not secondary to any other conditions."
• 2024-03-13: 2024 Annual review. No changes to clinical content. Updated references.
• 2023-10-16: Program update to standard reauthorization language. No changes to clinical intent.
• 2023-06-16: Attached EHB formulary.
• 2023-04-14: New program for Syfovre.

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