Subject: Empaveli SGM 4738-A P2026

Drug

EMPAVELI  (pegcetacoplan)

Policy:

Indications

The indications below including FDA-approved indications and compendial uses are considered a covered benefit provided that all the approval criteria are met and the member has no exclusions to the prescribed therapy.

FDA-approved Indications¹

Empaveli is indicated for:

• Treatment of adult patients with paroxysmal nocturnal hemoglobinuria (PNH).
• Treatment of adult and pediatric patients aged 12 years and older with C3 glomerulopathy (C3G) or primary immune-complex membranoproliferative glomerulonephritis (IC-MPGN), to reduce proteinuria.

Documentation

Submission of the following information is necessary to initiate the prior authorization review:

For initial requests:

• Paroxysmal nocturnal hemoglobinuria (PNH): Flow cytometry used to show results of glycosylphosphatidylinositol-anchored proteins (GPI-APs) deficiency.
• Complement 3 glomerulopathy (C3G) or primary immune-complex membranoproliferative glomerulonephritis (IC-MPGN):
  • Kidney biopsy confirming a diagnosis of complement 3 glomerulopathy (C3G) or primary immune-complex membranoproliferative glomerulonephritis (IC-MPGN).
  • Laboratory report and/or chart note(s) indicating the member has proteinuria greater than or equal to 1 g/day or baseline urine protein-to-creatinine ratio (UPCR) greater than or equal to 1.0 g/g obtained within 3 months prior to initiation of the requested drug.

For continuation requests:

• Paroxysmal nocturnal hemoglobinuria (PNH): Chart notes or medical record documentation supporting positive clinical response.
• Complement 3 glomerulopathy (C3G) or primary immune-complex membranoproliferative glomerulonephritis (IC-MPGN): Laboratory report and/or chart note(s) indicating the member has decreased levels of proteinuria or UPCR from baseline.

Prescriber Specialties

This medication must be prescribed by or in consultation with one of the following:

• Complement 3 glomerulopathy (C3G) or primary immune-complex membranoproliferative glomerulonephritis (IC-MPGN): nephrologist.

Coverage Criteria

Paroxysmal Nocturnal Hemoglobinuria (PNH)^1-6

Authorization of 6 months may be granted for treatment of paroxysmal nocturnal hemoglobinuria (PNH) when all of the following criteria are met:

• The diagnosis of PNH was confirmed by detecting a deficiency of glycosylphosphatidylinositol-anchored proteins (GPI-APs) (e.g., at least 5% PNH cells, at least 51% of GPI-AP deficient poly-morphonuclear cells).
• Flow cytometry is used to demonstrate GPI-APs deficiency.
• Member has and exhibits clinical manifestations of disease (e.g., lactate dehydrogenase [LDH] > 1.5 upper limit of normal [ULN], thrombosis, renal dysfunction, pulmonary hypertension, dysphagia).
• The requested medication will not be used in combination with another complement inhibitor (e.g., Fabhalta, Piasky, Soliris, Ultomiris) for the treatment of PNH (for eculizumab and ravulizumab transition to Empaveli is allowed).

Complement 3 Glomerulopathy (C3G) or Primary Immune-Complex Membranoproliferative Glomerulonephritis (IC-MPGN)¹

Authorization of 12 months may be granted for treatment of complement 3 glomerulopathy (C3G) or primary immune-complex membranoproliferative glomerulonephritis (IC-MPGN) when all of the following criteria are met:

• Member has a diagnosis of complement 3 glomerulopathy (C3G) or primary immune-complex membranoproliferative glomerulonephritis (IC-MPGN) confirmed by kidney biopsy.
• Member has either of the following obtained within 3 months prior to initiation of the requested drug:
  • Proteinuria greater than or equal to 1 g/day.
  • UPCR greater than or equal to 1.0 g/g.
• Member has received a stable dose of maximally tolerated renin-angiotensin system (RAS) inhibitor therapy (e.g., angiotensin converting enzyme inhibitor [ACEI] or angiotensin II receptor blocker [ARB]) and/or sodium-glucose cotransporter-2 (SGLT2) inhibitor therapy for at least 3 months prior to initiation of therapy, or member has an intolerance or contraindication to RAS inhibitors or SGLT2 inhibitor.

Continuation of Therapy

Paroxysmal Nocturnal Hemoglobinuria (PNH)

Authorization of 12 months may be granted for continued treatment in members requesting reauthorization when all of the following criteria are met:

• There is no evidence of unacceptable toxicity or disease progression while on the current regimen.
• The member demonstrates a positive response to therapy (e.g., improvement in hemoglobin levels, normalization of lactate dehydrogenase [LDH] levels).
• The requested medication will not be used in combination with another complement inhibitor (e.g., Fabhalta, Piasky, Soliris, Ultomiris) for the treatment of PNH.

Complement 3 Glomerulopathy (C3G) or Primary Immune-Complex Membranoproliferative Glomerulonephritis (IC-MPGN)

Authorization of 12 months may be granted for continued treatment in members requesting reauthorization when all of the following criteria are met:

• There is no evidence of unacceptable toxicity or disease progression while on the current regimen.
• The member is experiencing benefit from therapy as evidenced by either of the following:
  • Decreased levels of proteinuria from baseline.
  • Decrease in UPCR from baseline.

Place of Service:

Outpatient

The above policy is based on the following references:

1. Empaveli [package insert]. Waltham, MA: Apellis Pharmaceuticals, Inc.; July 2025.
2. Parker CJ. Management of paroxysmal nocturnal hemoglobinuria in the era of complement inhibitory therapy. Hematology. 2011; 21-29.
3. Borowitz MJ, Craig F, DiGiuseppe JA, et al. Guidelines for the Diagnosis and Monitoring of Paroxysmal Nocturnal Hemoglobinuria and Related Disorders by Flow Cytometry. Cytometry B Clin Cytom. 2010: 78: 211-230.
4. Preis M, Lowrey CH. Laboratory tests for paroxysmal nocturnal hemoglobinuria (PNH). Am J Hematol. 2014;89(3):339-341.
5. Parker CJ. Update on the diagnosis and management of paroxysmal nocturnal hemoglobinuria. Hematology Am Soc Hematol Educ Program. 2016;2016(1):208-216.
6. Dezern AE, Borowitz MJ. ICCS/ESCCA consensus guidelines to detect GPI-deficient cells in paroxysmal nocturnal hemoglobinuria (PNH) and related disorders part 1 - clinical utility. Cytometry B Clin Cytom. 2018 Jan;94(1):16-22.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

February 14, 2026