Q5170, Injection, aflibercept-boav (eydenzelt), biosimilar, 1 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Initial therapy requires diagnosis, maximum 12 intravitreal VEGF/dual VEGF-Ang-2 inhibitor doses per year per eye, and authorization for up to 12 months.
Key Coverage Criteria
- 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.
- Eylea (aflibercept) is proven and medically necessary for diabetic macular edema, diabetic retinopathy, macular edema following retinal vein occlusion, neovascular age-related macular degeneration, and retinopathy of prematurity.
3 Active Policies
UHC-POL-ophthalmologic-vegf-inhibitors, Ophthalmologic Vascular Endothelial Growth Factor (VEGF) Inhibitors
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
Related Codes
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