Macugen® (pegaptanib)

No prior authorization required for:

  • Emergency room
  • Inpatient
  • Skilled nursing facility

For further information, please see the Injectable Drugs page

Code(s): J2503

Benefit: Medical

Notes

  • Prior use of Avastin® (bevacizumab)
  • 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-E08.3513, 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 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-H34.8132, Central retinal vein occlusion
H35.3210-H35.3233, Exudative age-related macular degeneration