For GA, secondary to AMD
NAVIGATING PAYER COVERAGE
See how SYFOVRE️is covered
Coverage policies are subject to change and vary from plan to plan.
100% SYFOVRE payer coverage for Traditional Medicare and robust coverage for Medicare Advantage and Commercial lives in the United States1,a
aData as of January 2025.
Navigating the prior authorization (PA) process
Some health plans may require a PA describing your patient’s medical history and the reasons why you feel SYFOVRE is the right medication for your patient. Other plans may require a precertification for the CPT code based on site of care. It is important to check with your patient’s health plan to ensure you are using the correct form and supplying all of the required information. To avoid delays, it is recommended to consider including a Letter of Medical Necessity to support the PA submission.
Refer to the checklist and resources below for guidance on fulfilling PA requirements. Or contact your Apellis Field Reimbursement Manager (FRM) or call ApellisAssist at 888-APELLIS (888-273-5547) for information on PA requirements.
PA checklist
Helpful reminders for the PA process
- Confirm PA requirements and how the PA should be submitted (eg, fax, phone, or online)
- Determine if the health plan has a specific form that must be used and if it is available online
- Check the health plan’s policy for treatment with SYFOVRE to ensure medical documentation addresses specific policy requirements
- Use the appropriate billing codes
Refer to the Access & Reimbursement Guide
for more information
Letter of Medical Necessity
(some payers may require this)
- Be specific in your request (ie, requesting approval of the PA to support the prescribed medication)
- Highlight the clinical assessments that demonstrate the patient need and that the patient meets the health plan medical policy criteria for treatment with SYFOVRE
- Include a copy of the health plan medical policy, if available
- Include your office’s contact information
Refer to the Sample Letter of Medical Necessity
for examples of the types of information you may want to include
What happens next?
- If the PA is approved, be sure to document the PA approval number/date in the patient’s record and make note of the expiration date
- If the PA is denied, you can file an appeal. The ApellisAssist program can provide information about how to submit the appeal. The following PA denial appeal checklist may be helpful as you’re preparing an appeal:
- Review the denial letter to understand the reason for the denial and note any deadlines for next steps
- Compile supporting medical information, documentation, and clinical assessments
- Submit the first appeal per the health plan’s process and requirements
- If rejected, submit a second appeal that responds to the health plan’s concerns, questions, or requirements
- Many health plans’ appeal policies allow up to 2 levels of internal appeal for PA denials. You may have the right to request an external appeal, which can include a review by an independent expert not affiliated with the health plan or an external review board. Be sure to note any deadlines for these additional appeals
Refer to the Sample Letter of Appeals for examples of the types of information you may want to include
AMD=age-related macular degeneration; GA=geographic atrophy.
Reference: 1. Data on file. Apellis Pharmaceuticals, Inc; 2024.
