Q5155, Injection, aflibercept-jbvf (yesafili), biosimilar, 1 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
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.
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.
- Therapies must be proven effective for the relevant diagnosis or procedure to be considered for coverage.
8 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
OTH903.027, Aflibercept and Associated Biosimilar(s)
BCBSIL-OTH903.027, Aflibercept and Associated Biosimilar(s)
Related Codes
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