Does J2777 require prior authorization?

Yes, J2777 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J2777?

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

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`J2777`, Injection, faricimab-svoa, 0.1 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires 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).

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.

Coverage determinations for off-label use require supporting peer-reviewed literature, specialty consultant advice as indicated, and reference to accepted standards of medical practice; documentation of these sources must be provided for review.

Provider requests to add an off-label use must be submitted in writing with supporting data consisting of either at least two Phase III trials demonstrating safety and effectiveness, or if no Phase III evidence exists, at least two large Phase II trials from different centers or other overwhelming Phase II evidence for rare diseases.

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.
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.
Intravitreal injection of faricimab-svoa (Vabysmo) may be considered medically necessary for neovascular (wet) age-related macular degeneration, diabetic macular edema, or macular edema following retinal vein occlusion.
Faricimab-svoa (Vabysmo®) may be considered medically necessary for the treatment of neovascular (wet) age-related macular degeneration, diabetic macular edema, or macular edema following retinal vein occlusion.
Faricimab-svoa (Vabysmo®) may be considered medically necessary for neovascular (wet) AMD, diabetic macular edema, or macular edema following retinal vein occlusion.

17 Active Policies

ARKBLUE-NON-BEVACIZUMAB-VASCULAR-EPITHELIAL-GROWTH-FACTO-DADB84DA02, Non-Bevacizumab Vascular Epithelial Growth Factors for Ophthalmic Use (e.g., Beovu, Byooviz, Cimerli, Eylea, Eylea HD, Lucentis, Pavblu, Vabysmo, Enzeevu, Ahzantive, Yesafili, Opuviz)

FLORIDA_BLUE-FLBLUE-VABYSMOTM-FARICIMAB-SVOA-C5ABA7E68E, Vabysmo (faricimab-svoa)

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

BCBSM-2157470-F099DCE7BE, VABYSMO (FARICIMAB-SVOA)

HEALTHNET_OR-HNOR-FARICIMAB-SVOA-VABYSMO-CP-PHAR-581-16D310824E, Faricimab-svoa (Vabysmo) ; CP.PHAR.581

MODA-VABYSMO-374EE71FE7, Vabysmo (faricimab-svoa)

EVICORE-MEDICAL_DRUG-91AEA7317873, Vabysmo (faricimab-svoa intravitreal)

UHC-POL-ophthalmologic-vegf-inhibitors, Ophthalmologic Vascular Endothelial Growth Factor (VEGF) Inhibitors

BCBSIL-OTH903.044, Faricimab-svoa

BCBSMT-OTH903.044, Faricimab-svoa

BCBSNM-OTH903.044, Faricimab-svoa

BCBSOK-OTH903.044, Faricimab-svoa

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

BCBSTN-53830922dd, Faricimab-svoa (Vabysmo)

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J2777, Injection, faricimab-svoa, 0.1 mg