Jetrea^® (ocriplasmin)

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): J7316

Benefit: Medical

Notes:

• Treatment of vitreomacular adhesion
• No prior authorization required
• Covered only for diagnoses H43.821-H43.829, vitreomacular adhesion