Does Q5128 require prior authorization?

Yes, Q5128 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for Q5128?

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

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`Q5128`, Injection, ranibizumab-eqrn (cimerli), biosimilar, 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).

"the individual requiring treatment must be diagnosed with one of the following FDA-approved indications or approved compendial use and meet the specific coverage guidelines for the covered indication."

No additional specific documentation requirements (e.g., required testing results, visual acuity thresholds, prior therapy trials) are specified in this document beyond diagnosis, meeting the coverage guidelines for the indication, and administration/supervision by an ophthalmologist.

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.
Neovascular (wet) age-related macular degeneration (AMD)
Macular edema following retinal vein occlusion (RVO)
Diabetic macular edema (DME)

16 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)

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

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

MODA-LUCENTIS-C9F873B020, Ranibizumab: Lucentis; Byooviz; Cimerli

HEALTHNET_OR-HNOR-RANIBIZUMAB-BYOOVIZ-CIMERLI-LUCENTIS-NUFYMCO-SUSVIMO-CP-32A05AF835, Ranibizumab (Byooviz, Cimerli, Lucentis, Nufymco, Susvimo); CP.PHAR.186

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

BCBSTN-fd00a6c045, Ranibizumab (Lucentis, Byooviz; Cimerli)

BCBSIL-OTH903.041, Ranibizumab Injections, Implants and Biosimilars

BCBSMT-OTH903.041, Ranibizumab Injections, Implants and Biosimilars

BCBSNM-OTH903.041, Ranibizumab Injections, Implants and Biosimilars

BCBSOK-OTH903.041, Ranibizumab Injections, Implants and Biosimilars

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

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

EVICORE-MEDICAL_DRUG-450AA68F3E04, Ranibizumab (Lucentis, Byooviz, and Cimerli) Injection

EVICORE-MEDICAL_DRUG-9F18EE037CAB, Ranibizumab (Lucentis, Byooviz, Nufymco and Cimerli) InjectionEffective 10/01/2026

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Q5128, Injection, ranibizumab-eqrn (cimerli), biosimilar, 0.1 mg