Codes & NDC
| HCPCS | J0178 — "Inj, aflibercept, 1 mg" (permanent code; 1 mg = 1 unit) |
|---|
| NDC (vial) | 61755-005-02 (10) / 61755-0005-02 (11) — 2 mg / 0.05 mL SDV |
|---|
| NDC (PFS) | 61755-005-01 (10) / 61755-0005-01 (11) — 2 mg / 0.05 mL prefilled syringe |
|---|
| Vial | 2 mg / 0.05 mL of 40 mg/mL solution (single-dose) |
|---|
| Route | Intravitreal injection |
|---|
| Benefit | Medical (provider buy-and-bill); not specialty pharmacy |
|---|
Aflibercept biosimilars (do NOT bill under J0178)
| Q-code | Brand (mfr) | Interchg. |
|---|
Q5147 | Pavblu (Amgen) | No |
Q5149 | Enzeevu (Sandoz) | No |
Q5150 | Ahzantive (Formycon) | No |
Q5153 | Opuviz (Samsung Bioepis) | Yes |
Q5155 | Yesafili (Biocon) | Yes |
Substitution risk: If pharmacy dispenses biosimilar, the Q-code must drive the claim — not J0178. Lot NDC must reconcile with billed code.
Dosing per indication
| Indication | Schedule |
|---|
| wAMD | 2 mg q4wk × 3 loading, then q8wk (some extend q12wk) |
| DME | 2 mg q4wk × 5, then q8wk |
| DR | 2 mg q4wk × 5, then q8wk (or q4wk × 3, then q8–q16wk per extension) |
| RVO (CRVO/BRVO) | 2 mg q4wk |
| ROP (pediatric) | 0.4 mg per protocol — Eylea 2 mg only, NOT Eylea HD |
Bilateral billing (RT/LT, not -50)
Most payers require two separate lines for bilateral same-day:
- Line 1:
67028-RT + J0178-RT 2 units
- Line 2:
67028-LT + J0178-LT 2 units
Some commercial payers accept 67028-50 (1 unit, fee × 2). Verify per payer.
Modifiers
| Mod | When |
|---|
RT / LT | Required on both J0178 and 67028 lines |
E1–E4 | Some payers require eyelid quadrant in addition to RT/LT |
JZ | Required when no drug discarded (typical for SDV/PFS) |
JW | Only if discarded amount ≥ threshold (rare for 2 mg SDV/PFS) |
25 | On E/M when separately identifiable |
XU / 59 | To unbundle OCT/fundus photo from 67028 |
ICD-10 (most common)
| Code | For |
|---|
H35.32xx | Wet AMD (5th/6th char = laterality + stage) |
E11.341x / E10.341x | DME in T2DM / T1DM (severe NPDR + ME) |
E11.351x | PDR + DME in T2DM |
E11.331x / E11.321x | Mod / Mild NPDR with DME |
E11.319 / E10.319 | DM with unspec DR without ME |
H34.81xx / H34.83xx | CRVO / BRVO with macular edema |
H44.2x + H35.05 | Degenerative myopia + secondary CNV (mCNV) |
H35.10–H35.17 | ROP (Eylea 2 mg only) |
H35.81 | Retinal edema (adjunct only) |
Match laterality. ICD-10 5th-char laterality must match RT/LT modifier on procedure lines.
Payer requirements (May 2026)
| Payer | PA | Step / Preference |
|---|
| UnitedHealthcare | Yes | Yes — bevacizumab first; biosimilar (Pavblu/Yesafili/Opuviz) preferred over reference Eylea |
| Aetna commercial | Yes | Bevacizumab trial requested; biosimilar pathway preferred |
| Aetna Medicare Part B | Yes | Non-preferred (favors bevacizumab + 2 mg biosimilars) |
| BCBS (most plans) | Yes | Bevacizumab trial; many now prefer Pavblu Q5147 |
Two simultaneous UM levers in 2026: bevacizumab step AND biosimilar preference. Document both.
Medicare reimbursement (Q2 2026)
| Field | Value |
|---|
| ASP + 6% | $731.885 / mg (effective 4/1 – 6/30/2026) |
| 2 mg dose | $1,463.77 (2 units × $731.885) |
| After ~2% sequestration | ~$1,434 (actual paid, ~ASP+4.3%) |
| Pavblu Q5147 ASP+6% | ~$821.40/mg (~$1,642.79 / 2 mg dose) |
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. Intravitreal must be in-office or ASC.
Patient assistance — EYLEA4U
- EYLEA4U: 1-855-EYLEA4U / 1-855-395-3248, Option 4 (M–F 9–8 ET) — shared for Eylea + Eylea HD
- Commercial copay: as low as $0/treatment (excludes Medicare/Medicaid/federal)
- PAP: free drug for uninsured/underinsured
- EYLEA Direct: Regeneron's direct-purchase program (alternative to specialty distributor)
- Medicare patients: verify open foundation funds (PAN, HealthWell)
- Provider portal: eyleahcp.com
Warnings & Precautions
- Endophthalmitis & retinal detachments from intravitreal injection — aseptic technique, monitor post-injection
- Increased IOP within 60 min of injection — check IOP & perfusion of optic nerve head
- Arterial thromboembolic events (NASCET-defined: stroke, MI, vascular death)
Different drug, different code: Eylea HD = J0177, NDC 61755-050, 8 mg / 8 units. Common denial: 8 units of J0178 for an HD dose. Verify formulation in chart before billing.