J0178, Injection, aflibercept, 1 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Documentation Required
- Medical record must document indication, route (intravitreal), dose and dosing frequency consistent with the FDA label or include literature support when dosing/frequency deviates from the FDA label.
- The intravitreal administration must be billed with CPT 67028 on the same claim as the drug (or CPT 67027 for SUSVIMO) and must include the appropriate site modifier (RT, LT, or 50).
- For Part A and Part B MAC claims, report the drug using the specified HCPCS/J-codes or Q-codes as listed by product (e.g., ranibizumab J2778/J2779 or Q5124/Q5128, aflibercept J0178 or J0177/Q-codes for biosimilars, brolucizumab-dbll J0179, faricimab-svoa J2777).
- Claims for aflibercept must include the appropriate HCPCS/J‑codes (J0177, J0178, Q5147, Q5149, Q5150, Q5153, or Q5155) and CPT code 67028 on CMS Form 1500.
- When different anti‑VEGF agents are injected into each eye on the same DOS, document the clinical rationale in the medical record and append the correct RT/LT modifier to the corresponding drug line item.
- No explicit Medicare/coverage-specific documentation requirements are stated in this document.
Key Coverage Criteria
- Intravitreal administration of ranibizumab (including ranibizumab-nuna and ranibizumab-eqrn), aflibercept (including aflibercept HD and biosimilars PAVBLU™, AHZANTIVE®, ENZEEVU™, OPUVIZ™, YESAFILI™), brolucizumab-dbll, and faricimab-svoa is covered when used consistent with the FDA-approved package insert or supported compendia/literature for off-label uses.
- Aflibercept (EYLEA) is FDA‑approved for treatment of neovascular (wet) age‑related macular degeneration (AMD) by intravitreal injection.
- Aflibercept (EYLEA) is FDA‑approved for treatment of macular edema following retinal vein occlusion (RVO) by intravitreal injection.
- Aflibercept (EYLEA) is FDA‑approved for treatment of diabetic macular edema (DME) by intravitreal injection.
- Aflibercept (EYLEA) is FDA‑approved for treatment of diabetic retinopathy (DR) by intravitreal injection.
- Initial therapy for ophthalmologic VEGF/Ang-2 inhibitors requires (1) diagnosis, (2) intravitreal VEGF or dual VEGF/Ang-2 inhibitor administration limited to 12 doses per year per eye, and (3) authorization for a maximum of 12 months.
17 Active Policies
A52451, Billing and Coding: Ranibizumab and biosimilars, Aflibercept, Aflibercept HD, Brolucizumab-dbll, Faricimab-svoa, PAVBLUaflibercept-ayyh, AHZANTIVEaflibercept-abzv. ENZEEVUaflibercept-mrbb, OPUVIZaflibercept-yszy and YESAFILI aflibercept-jbvf
J6
NGS-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses
JK
AETNA-CPB-0765, Age-Related Macular Degeneration
AETNA-CPB-0484, Glaucoma Surgery
OTH903.027, Aflibercept and Associated Biosimilar(s)
BCBSIL-OTH903.027, Aflibercept and Associated Biosimilar(s)
BCBSIL-OTH903.015, Photodynamic Therapy for Choroidal Neovascularization
BCBSMT-OTH903.027, Aflibercept and Associated Biosimilar(s)
BCBSMT-OTH903.015, Photodynamic Therapy for Choroidal Neovascularization
BCBSNM-OTH903.027, Aflibercept and Associated Biosimilar(s)
BCBSNM-OTH903.015, Photodynamic Therapy for Choroidal Neovascularization
BCBSOK-OTH903.027, Aflibercept and Associated Biosimilar(s)
BCBSOK-OTH903.015, Photodynamic Therapy for Choroidal Neovascularization
UMR-POL-UMR-ophthalmologic-vegf-inhibitors, Ophthalmologic Vascular Endothelial Growth Factor (VEGF) Inhibitors
SUREST-POL-SUREST-ophthalmologic-vegf-inhibitors, Ophthalmologic Vascular Endothelial Growth Factor (VEGF) Inhibitors
UHC-POL-ophthalmologic-vegf-inhibitors, Ophthalmologic Vascular Endothelial Growth Factor (VEGF) Inhibitors
A53387, Billing and Coding: Aflibercept (EYLEA)
Related Codes
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