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Eylea (aflibercept)


Billing

Code: J0178

Description: Aflibercept injection

Unit: 1 mg

Payment: $868.241

Pay quarter: Q4 2023


Medicare history

Dosage and Frequency

Neovascular (Wet) Age-Related Macular Degeneration (AMD)

Induction:
• 2mg IVT every 1 month for the first 3 months

Maintenance:
• 2mg IVT every 2 months

Macular Edema Following Retinal Vein Occlusion (RVO)

• 2mg IVT every 1 month

Diabetic Macular Edema (DME)
Diabetic Retinopathy (DR)

Induction:
• 2mg IVT every 1 month for the first 5 injections

Maintenance:
• 2mg IVT every 2 months

Calculate drug reimbursement


Total Reimbursement:

$1,736.48

(ASP: $1,638.19, Margin: $98.29)


Code:

J0178

# Units to bill:

2

Prior Authorization

Prior auth criteria for Eylea may include but is not limited to:


1. Patient must have been diagnosed with neovascular age-related macular degeneration (AMD).
2. All other anti-VEGF treatments (e.g. ranibizumab, aflibercept) must have been tried and failed, or not tolerated.
3. Patient must have evidence of active choroidal neovascularization (CNV), with fluid or lipid present on optical coherence tomography (OCT).
4. The patient must have an active lesion (with fluid or lipid present on OCT) at the time of treatment initiation.
5. The patient must be at least 18 years of age.
6. The patient must have an intraocular pressure (IOP) of less than 22 mmHg.
7. The patient must have a best-corrected visual acuity (BCVA) of 35 letters or worse on the Early Treatment Diabetic Retinopathy Study (ETDRS) chart.
8. The patient must have adequate kidney function as determined by creatinine clearance or estimated glomerular filtration rate (eGFR).


Insurance prior auth guidelines:

Aetna

United Healthcare

Anthem

Cigna


Billable NDCs

61755-0005-01

Eylea (REGENERON PHARMACEUTICALS INC.)

2 MG


61755-0005-02

EYLEA (REGENERON PHARMACEUTICALS INC.)

2 MG



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