Eylea® (aflibercept)

No prior authorization required for:

  • Emergency room
  • Inpatient
  • Skilled nursing facility

Injectable auth/billing notes:

Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.

Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.

Code(s): J0178

Benefit: Medical

Notes: Treatment of age-related macular degeneration and macular edema following central retinal vein occlusion

Medicare: No authorization required. Covered only when billed with the following ICD-10 diagnoses:

E08.311, Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema
E08.3211 – E08.3213, Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema
E08.3311 – E08.3313, Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema
E08.3411 – E08.3413, Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema
E08.3511 – E083513, Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema
E09.311, Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema
E09.3211 – E09.3213, Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E09.3311 – E09.3313, Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E09.3411 – E09.3413, Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E09.3511 – E09.3513, Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema
E10.311, Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E10.3211 – E10.3213, Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E10.3311 – E10.3313, Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E10.3411 – E10.3413, Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E10.3411 – E10.3413, Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E10.3511 – E10.3513, Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema
E11.311, Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E11.3211 – E11.3213, Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E11.3311 – E11.3313, Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E11.3411 – E11.3413, Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E11.3511 – E11.3513, Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema
E13.311, Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema
E13.3211- E13.3213, Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E13.3311 – E13.3313, Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E13.3411 – E13.3413, Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E13.3511 – E13.3513,   Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema
H34.8110-H34.8122, Central retinal vein occlusion
H34.8310-H34.8332, Tributary (branch) retinal vein occlusion, 
H35.051 – H35.053, Retinal neovascularization, unspecified
H35.3210 – H35.3233,  Exudative age-related macular degeneration
H35.81, Retinal edema