C9151 Inj, pegcetacoplan 1 mg

Injection, pegcetacoplan, 1 mg

Payer policies and prior authorization for C9151

11 of 12 payer prior-auth lists that name C9151 require prior authorization or set conditions: Molina Healthcare of Iowa, Molina Healthcare of Ohio, Rocky Mountain Health Plans, UnitedHealthcare Community Plan.

PayerPlanStatePrior authConditionsSinceSource
Molina Healthcare of IowaMedicaidIAprior auth requiredJul 1, 2023IA Prior Authorization Matrix, effective Q3 2023
Molina Healthcare of OhioMedicaid and MyCare Ohio (MMP) MedicaidOHprior auth requiredOct 1, 2023Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of OhioMedicare and MyCare Ohio (MMP) MedicareOHprior auth requiredOct 1, 2023Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of OhioExchangeOHprior auth requiredOct 1, 2023Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Rocky Mountain Health PlansRocky Mountain Medicare Advantage D-SNPCOprior auth requiredFeb 1, 2025Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025
UnitedHealthcare Community PlanMassachusetts Senior Care Options (SCO)MAprior auth under conditions*For unclassified and temporary codesNov 1, 2025CPT® is a registered trademark of the American Medical Association. Prior authorization requirements for Massachusetts Senior Care Options Effective November 1, 2025
UnitedHealthcare Community PlanMassachusetts Senior Care Options (SCO)MAprior auth requiredNov 1, 2025CPT® is a registered trademark of the American Medical Association. Prior authorization requirements for Massachusetts Senior Care Options Effective November 1, 2025
UnitedHealthcare Community PlanMinnesota Metro MedicaidMNprior auth requiredOct 1, 2024Prior authorization requirements for Minnesota Medicaid Effective October 1, 2024
UnitedHealthcare Community PlanTennCareTNprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026
UnitedHealthcare Community PlanUnitedHealthcare Community Plan of FloridaFLprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHeathcare Community Plan of Florida Effective October 1, 2026
UnitedHealthcare Community PlanUnitedHealthcare Community Plan of New YorkNYprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026

Payer coverage policies that name C9151

C9151 appears in 3 coverage policies from Aetna, UnitedHealthcare, Wellmark Blue Cross Blue Shield.

PayerPolicyRole in policyReviewedDocument
AetnaInjectable Medications (0020)listed, no stance (range C8957-C9235)Mar 5, 2026payer document
UnitedHealthcareMaximum Dosage and Frequency (for Pennsylvania Only) (CSPA2026D0034AS)listed, no stanceMay 1, 2026payer document
Wellmark Blue Cross Blue ShieldComplement Inhibitors for Geographic Atrophy: Izervay (avacincaptad pegol injection) Syfovre (pegcetacoplan injection) (05.04.98)listed, no stanceOct 1, 2025payer document

Recent prior-auth changes

  • Oct 1, 2025: conditions changed, UnitedHealthcare Community Plan
  • Jan 1, 2025: PA removed, UnitedHealthcare
  • Sep 1, 2023: PA removed, Blue Shield of California Promise Health Plan
  • Jul 1, 2023: PA added, Molina Healthcare of Ohio
  • Jul 1, 2023: PA added, Molina Healthcare of Ohio
  • Jul 1, 2023: PA added, Blue Shield of California Promise Health Plan
  • Jul 1, 2023: PA added, Molina Healthcare of Ohio

Medicaid fee-for-service

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.