Codes & NDC
| HCPCS | J0179 — "Inj, brolucizumab-dbll, 1 mg" (permanent J-code) |
|---|
| NDC (vial kit) | 0078-0827-61 (10) / 00078-0827-61 (11) — vial + filter needle |
|---|
| NDC (PFS) | 0078-0827-60 (10) / 00078-0827-60 (11) — prefilled syringe |
|---|
| Concentration | 120 mg/mL solution; 6 mg in 0.05 mL |
|---|
| Benefit | Medical (provider buy-and-bill); not specialty pharmacy |
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| Approved | Oct 2019 wAMD (BLA 761125); Jun 2022 DME; Jun 2020 IOI/RV/RO label update |
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Dosing per indication
| Indication | Schedule |
|---|
| wAMD | 6 mg monthly × 3 (loading), then q8–12 wk |
| DME | 6 mg q6 wk × 5 doses, then q8–12 wk |
Pediatric: safety not established. Off-label for RVO, DR without DME, myopic CNV — most payers deny.
Bilateral billing (RT/LT, not -50)
Most payers require two separate lines for bilateral same-day:
- Line 1:
67028-RT + J0179-RT 6 units
- Line 2:
67028-LT + J0179-LT 6 units
Some commercial payers accept 67028-50 (1 unit, fee × 2). Verify per payer.
Bilateral Beovu doubles IOI/RV/RO risk. Most retina specialists avoid same-day bilateral; sequence injections instead.
Modifiers
| Mod | When |
|---|
RT / LT | Required on both J0179 and 67028 lines |
JZ | Required — package sized to full 6 mg dose, zero discard |
JW | Rarely applies (≥1 mg waste only) |
25 | On E/M when separately identifiable |
XU / 59 | To unbundle OCT/fundus photo from 67028 |
NCCI bundling alert
| Code | Service |
|---|
92133 / 92134 | OCT — bundled |
92250 | Fundus photo — bundled |
92235 / 92240 | FA / ICG angiography — generally separately reimbursable when documented (e.g., suspected occlusive vasculitis) |
99211–99215 | E/M — bundled (use mod 25) |
ICD-10 (most common)
| Code | For |
|---|
H35.32xx | Wet AMD (5th/6th char = laterality + stage) |
E11.311 / E10.311 | DM with DR + DME, severity unspecified |
E11.321 / E11.331 | Mild / Moderate NPDR with DME (T2DM) |
E11.341 / E11.351 | Severe NPDR / PDR with DME (T2DM) |
H34.81xx | OFF-LABEL — RVO not approved |
Match laterality. ICD-10 5th-char laterality must match RT/LT modifier on procedure lines.
Payer requirements (May 2026)
| Payer | PA | Step therapy |
|---|
| UnitedHealthcare | Yes | Yes — 2 prior anti-VEGF failures (least preferred) |
| Aetna | Yes | Yes — non-preferred (CPB 0701; MA Ref 2507-A) |
| Carelon / Anthem | Yes | Yes — 2 prior failures + IOI/RV/RO risk-benefit attestation |
| BCBS (most plans) | Yes | Yes — least preferred tier |
Heavy step therapy is the norm. Document ≥2 prior anti-VEGF failures (drug, dose, dates, OCT response). Some payers require IOI/RV/RO consent attestation.
Medicare reimbursement (Q2 2026)
| Field | Value |
|---|
| ASP + 6% | $353.069 / mg (effective 4/1 – 6/30/2026) |
| 6 mg dose | $2,118.41 (6 × $353.069) |
| After ~2% sequestration | ~$2,076 (actual paid) |
| NCD/LCD | None drug-specific; covered for on-label wAMD/DME only |
Site of care
| Setting | POS | Form |
|---|
| Physician / retina office | 11 | CMS-1500 / 837P |
| Ophthalmology ASC | 24 | CMS-1500 / 837P |
| Hospital outpatient | 19/22 | UB-04 / 837I (UHC, Aetna disfavor) |
Home admin not applicable. No S/G-codes — intravitreal must be in-office or ASC.
Patient assistance — Novartis & foundations
- Novartis Patient Assistance Foundation (NPAF): 1-800-277-2254 — free drug for uninsured/underinsured (income-qualified)
- Beovu Co-Pay Program / Universal Co-Pay: commercial copay assistance (excludes Medicare/Medicaid/Tricare/VA/federal)
- Foundations (Medicare): Good Days, HealthWell — macular degeneration / retinal vascular funds; verify open quarterly
- Portal: pap.novartis.com · fax 1-855-817-2711
WARNINGS & PRECAUTIONS — IOI / Retinal Vasculitis / Retinal Vascular Occlusion. Per Jun 2020 label update: ~4% IOI and ~1% retinal artery occlusion in pivotal data; many cases occlusive and sight-threatening (~88% in women per ASRS ReST). Plus class warnings: endophthalmitis, retinal detachment, IOP rise, thromboembolic events. Discontinue at first sign of IOI/RV/RO.