Does J0178 require prior authorization?

No, J0178 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for J0178?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`J0178`, Injection, aflibercept, 1 mg

HCPCS/CPT

Prior Authorization

No Prior Auth Required

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).

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

NGS-J6-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

NGS-JK-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

AETNA-CPB-0484, Glaucoma Surgery

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)

AETNA-CPB-0765, Age-Related Macular Degeneration

`J0178`, Injection, aflibercept, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

17 Active Policies

Related Codes

Have a follow-up question?

J0178, Injection, aflibercept, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

17 Active Policies

Related Codes

Have a follow-up question?

`J0178`, Injection, aflibercept, 1 mg