HCPCS
J0177
1 mg = 1 unit
Phase 1
Identify what you're billing
Confirm the right code, dose, and NDC before building the claim.
Eylea HD vs. regular Eylea — J0177 vs. J0178 FDA verified Apr 2026
A common biller mistake. The 8 mg HD and 2 mg formulations are billed entirely differently.
Regeneron's aflibercept comes in two FDA-approved formulations: the original Eylea (2 mg), approved 2011, billed under HCPCS J0178; and Eylea HD (8 mg high-dose), approved August 2023, billed under HCPCS J0177 (permanent code effective April 1, 2024, replacing temporary code C9161). They are not interchangeable for billing — every code, NDC, and unit count differs.
| Eylea HD (8 mg) | Eylea (2 mg) | |
|---|---|---|
| HCPCS | J0177 | J0178 |
| NDC root | 61755-050 / 61755-051 | 61755-005 |
| Strength per dose | 8 mg / 0.07 mL | 2 mg / 0.05 mL |
| Billable units | 8 | 2 |
| Max dosing interval | up to 20 weeks (after year 1) | up to 16 weeks |
| Q2 2026 ASP+6% | ~$301.177/mg | varies (higher per-mg) |
| Biosimilars available | None | 6 (Yesafili, Opuviz, Pavblu, Ahzantive, Enzeevu, Eydenzelt) |
| FDA approval | August 2023 (BLA 761355) | November 2011 (BLA 125387) |
Disambiguation rule of thumb: if the chart says "Eylea HD," "8 mg," "0.07 mL," or
references the high-dose formulation, bill
J0177 × 8 units. If it says "Eylea" alone,
"2 mg," or "0.05 mL," bill J0178 × 2 units. The most common biller error: billing
8 units of J0178 for an Eylea HD dose — that denies because both the J-code and
the units are wrong for the drug administered.
This page covers Eylea HD (J0177). The Eylea (J0178) reference page is coming soon.
Dosing per indication FDA label Apr 2026
From FDA prescribing information, label revised April 2026 (BLA 761355). Four indications across two recent label expansions.
| Indication | Loading | Maintenance | Per dose |
|---|---|---|---|
| Wet AMD (wAMD) | 8 mg every 4 weeks × 3 doses | Every 8–16 weeks (±1 wk); up to 20 weeks after year 1 | 8 mg / 8 units |
| Diabetic Macular Edema (DME) | 8 mg every 4 weeks × 3 doses | Every 8–16 weeks (±1 wk); up to 20 weeks after year 1 | 8 mg / 8 units |
| Diabetic Retinopathy (DR) | 8 mg every 4 weeks × 3 doses | Every 8–12 weeks (±1 wk) | 8 mg / 8 units |
| Macular Edema following RVO | 8 mg every 4 weeks × 3–5 doses | Every 8 weeks | 8 mg / 8 units |
Recent label updates that affect billing:
- November 2025 (s010 supplement): Added DR and RVO indications; permitted optional Q4W (monthly) dosing for any indication.
- April 2026: Extended maintenance interval up to 20 weeks for wAMD/DME after one year of successful response (PULSAR/PHOTON 2-year data).
Pediatric
Per FDA label: "The safety and effectiveness of EYLEA HD in pediatric patients have not been established." No payer reviewed covers pediatric Eylea HD.
NDC reference FDA NDC Directory verified May 2026
| NDC (10-digit) | NDC (11-digit, claim form) | Package | Manufacturer |
|---|---|---|---|
61755-050-01 |
61755-0050-01 |
8 mg / 0.07 mL single-dose vial kit (most common configuration) | Regeneron |
61755-051-01 |
61755-0051-01 |
8 mg / 0.07 mL vial-only (alternative configuration) | Regeneron |
11-digit NDC required on most claim forms. Pad the middle segment with a leading zero:
61755-0050-01. Use the
N4 qualifier in CMS-1500 Box 24A shaded area, with
unit of measure (ML) and quantity (e.g., N461755005001ML0.07).
Prefilled syringe (PFS) update: Regeneron has filed for a prefilled syringe configuration of Eylea HD with the FDA, but as of May 2026 the FDA review is still ongoing and no PFS NDC has been assigned. Treat any "Eylea HD PFS" NDC as unverified until DailyMed adds it.
Phase 2
Code the claim
CPT 67028 + per-eye laterality + NCCI bundling pitfalls.
CPT 67028 & bilateral rules CPT verified May 2026
Intravitreal injections have unique laterality rules — per-eye billing, RT/LT preferred over modifier 50.
| Code | Description | Notes |
|---|---|---|
67028 |
Intravitreal injection of a pharmacologic agent (separate procedure) | Always pair with the J0177 drug line on the same claim. Append RT or LT for laterality. |
Bilateral same-day injections — RT/LT, not modifier 50
For bilateral Eylea HD injections on the same date of service, most payers require two separate line items:
- Line 1:
67028-RT, 1 unit, full fee - Line 2:
67028-LT, 1 unit, full fee
Some commercial payers accept the alternative single-line format with modifier 50:
67028-50, 1 unit, fee doubled
Per AAPC: "It is important to check with individual payers as some may require the procedure to be billed on two separate lines with -RT and -LT modifiers instead of using -50." Modifier 50 is not preferred for retina; RT/LT is the safer default.
Drug billing for bilateral: bill J0177 twice as well — one drug line per eye, each with
the matching RT or LT modifier. Each eye gets 8 units of J0177 + 1 unit of 67028.
Modifiers CMS verified May 2026
RT / LT — required for laterality
Append RT (right eye) or LT (left eye) to BOTH the J0177 drug line and the 67028 admin line. Without laterality, payer systems can't reconcile bilateral claims and will deny one or both lines.
JZ — required when no drug discarded
Effective July 1, 2023, CMS requires the JZ modifier on all single-dose container claims when no drug is discarded. Eylea HD's 0.07 mL single-dose vial is sized to the 8 mg dose, so wastage is typically zero or sub-1 mg. JZ applies to nearly every Eylea HD claim. Per Retina Today: "Retina drugs are frequently reported with modifier -JZ."
JW — rarely applies
Use JW only if ≥1 billable unit (1 mg) was actually wasted. Because the vial is sized to the dose, this is uncommon. If you do bill JW, the wasted units are reported on a separate line from the administered units, with documentation in the medical record.
Modifier 25 — same-day E/M
Append modifier 25 to the E/M code when a significant, separately identifiable E/M service is performed on the same day as the injection. Routine pre-injection workup is bundled. New clinical concerns or treatment-decision visits qualify; routine "see how the eye looks before the shot" does not.
NCCI bundling — OCT, fundus photo, and 67028 NCCI verified May 2026
Ophthalmology-specific bundling that drives a large share of retina claim denials.
CMS National Correct Coding Initiative (NCCI) bundles several diagnostic services with 67028 when performed same-day:
| Code | Service | NCCI relationship to 67028 |
|---|---|---|
92133 | SCODI optic nerve (OCT) | Bundled same-day; XU/59 unbundling possible with documentation |
92134 | SCODI retina (OCT) | Bundled same-day; XU/59 unbundling possible with documentation |
92250 | Fundus photography | Bundled same-day; XU/59 unbundling possible with documentation |
| Established-pt E/M (99211–99215) | Office visit | Bundled; use modifier 25 if separately identifiable |
| Eye visit codes (92012, 92014) | Comprehensive eye exam | Not bundled with 67028 by NCCI |
Common denial: Billing OCT (92134) on the same date as 67028 without a modifier. NCCI will
deny the bundled service. To unbundle, append
XU or 59 to the OCT line, with
documentation in the medical record showing the OCT informed a treatment decision distinct from the injection
itself (e.g., evaluating disease progression for an interval-extension decision). Without proper documentation,
the unbundling is audit-vulnerable.
Eye visit codes (92012, 92014) are NOT bundled with 67028, so they're often the better choice for the visit portion of an injection encounter.
ICD-10-CM diagnosis codes FY2026 verified May 2026
Use the most specific code supported by the encounter documentation.
| ICD-10 | Description | Use for |
|---|---|---|
H35.32xx | Exudative age-related macular degeneration | Wet AMD (wAMD); 5th & 6th characters specify laterality and stage (active CNV vs scar vs inactive) |
E11.341x | Type 2 DM with severe non-prolif diabetic retinopathy with macular edema | DME in T2DM |
E10.341x | Type 1 DM with severe non-prolif diabetic retinopathy with macular edema | DME in T1DM |
E11.351x | Type 2 DM with proliferative diabetic retinopathy with macular edema | PDR + DME in T2DM |
E11.331x / E11.321x | Moderate / Mild non-prolif DR with macular edema | DR by severity |
H34.81xx / H34.83xx | Central / Tributary retinal vein occlusion | Macular edema following RVO |
H35.81 | Retinal edema | Adjunct dx; not standalone for J0177 |
Pair the diagnosis with the laterality modifier on the procedure line. ICD-10 codes carry their
own laterality character (e.g., H35.3211 = wAMD right eye stage 1); the RT/LT on 67028 must match. Mismatch
between Dx laterality and procedure laterality is a denial trigger.
Site of care & place of service Verified May 2026
Eylea HD is administered in-office or in an ASC. Home administration does not apply for intravitreal injections.
Intravitreal injections must be performed by an ophthalmologist or qualified retina specialist in a setting with sterile injection capability. Home administration is not a valid pathway for Eylea HD, so home-infusion HCPCS codes (S9329, S9379, 99601, G0089) do not apply. The only legitimate sites of care are physician office, ophthalmology-based ASC, and hospital outpatient.
| Setting | POS | Claim form | Electronic |
|---|---|---|---|
| Physician / retina office | 11 | CMS-1500 | 837P |
| Ambulatory surgery center (ophth ASC) | 24 | CMS-1500 | 837P |
| Hospital outpatient | 22 | UB-04 / CMS-1450 | 837I |
| On-campus hospital outpatient | 19 | UB-04 / CMS-1450 | 837I |
Payer site-of-care steering
Both UnitedHealthcare and Aetna apply site-of-care utilization management to ophthalmology anti-VEGF injections, generally favoring office (POS 11) and ophth ASC (POS 24) over hospital outpatient (POS 19/22) due to higher facility fees. If your practice operates under a hospital's billing TIN, expect a payer challenge for hospital outpatient billing.
POS choice affects reimbursement. Office (POS 11) and ASC (POS 24) generally pay at higher
physician-fee-schedule rates for the drug, while hospital outpatient (POS 19/22) bills under OPPS/APC
bundling rules with separate facility-fee considerations. Confirm your payer's preferred site before
scheduling.
Claim form field mapping Regeneron 2025 + Retina Today
CMS-1500 / 837P (physician office, ASC; POS 11/24).
| Information | CMS-1500 box | Notes |
|---|---|---|
| NDC qualifier + 11-digit NDC + UoM + qty | 24A shaded area | Format: N461755005001ML0.07 |
| HCPCS J0177 + RT/LT + JZ | 24D (drug line) | One unit count = 8 (mg) |
| Drug units | 24G | 8 |
| CPT 67028 + RT/LT | 24D (admin line) | One unit per eye |
| ICD-10 | 21 | Specific H35.32xx / E11.341x / etc. |
| Dates of service | 24A | Same date for drug + admin lines |
| NPI | 17b | Rendering provider |
| PA number (when required) | 23 | Required by UHC, Aetna, most BCBS |
Source: Retina Today — How to Create Clean Claims; Regeneron J-Code Billing & Coding Brochure.
Phase 3
Get paid
Step therapy is real for Eylea HD. Plan ahead.
Payer policy snapshot Reviewed May 2026
Step therapy with bevacizumab is the dominant utilization-management lever for Eylea HD.
| Payer | PA? | Step therapy? | Quantity limit | DR/RVO covered? |
|---|---|---|---|---|
| UnitedHealthcare Ophth VEGF Inhibitors policy |
Yes | Yes — ≥3 doses bevacizumab w/ minimal response, intolerance, or contraindication | ≤12 doses/year per eye | Verify (recent label expansion) |
| Aetna CPB 0701; MA Ref 2507-A |
Yes | Yes — commercial requests bevacizumab trial; Medicare classifies Eylea HD non-preferred | FDA-label dosing | Yes (commercial); MA verify |
| BCBS (most plans) e.g., Blue Shield CA |
Yes | Generally yes — bevacizumab trial or contraindication required | FDA-label dosing | Verify per plan |
Step therapy is the dominant Eylea HD UM mechanism. Unlike many specialty biologics where
first-line approval is straightforward, anti-VEGF policies push patients through repackaged off-label
bevacizumab (Avastin) first. Document the bevacizumab trial (3 doses minimum at UHC, with measured response)
OR a clear contraindication / intolerance before requesting Eylea HD authorization.
Why step therapy here
Repackaged bevacizumab costs ~$50–100/dose vs. ~$2,500 for Eylea HD. There are no Eylea HD biosimilars (yet) to provide a cheaper alternative within the same molecule, so payers fall back on the off-label bevacizumab pathway for cost containment. This is fundamentally different from drugs with biosimilar competition (e.g., Stelara, Humira) where step therapy is biosimilar-first.
What to document for step-therapy approval
- Date(s) of bevacizumab injection(s), at least 3 doses
- Pre/post visual acuity and OCT measurements showing minimal response
- Persistent intraretinal/subretinal fluid on OCT after bevacizumab trial
- Any documented contraindication (allergy, prior thromboembolic event w/ bevacizumab) if skipping the trial
Medicare reimbursement CMS Q2 2026 (live)
Quarterly ASP from CMS Part B Drug Pricing File. Refreshes automatically each quarter.
Q2 2026 payment snapshot — J0177
Effective April 1 – June 30, 2026 · Based on 4Q25 ASP submissions
ASP + 6%
$301.177
per mg / per unit
8 mg dose
$2,409.42
8 units × ASP+6%
After sequestration
~$2,361
~2% reduction (actual paid)
Coverage
No NCD or LCD specific to Eylea HD. The relevant MAC billing & coding article is A52451 ("Billing and Coding: Ranibizumab and biosimilars, Aflibercept, Aflibercept HD, Brolucizumab-dbll, Faricimab-svoa..."). All MACs cover J0177 for FDA-approved on-label indications. Bill with a specific H35.32xx, E1x.34x/E1x.35x, or H34.81xx ICD-10.
Code history
- C9161 — temporary HCPCS (Hospital OPPS pass-through), effective Q4 2023, discontinued 3/31/2024
- J0177 — permanent code, effective April 1, 2024
Canonical code source: CMS HCPCS quarterly update file.
Patient assistance — EYLEA4U Regeneron verified May 2026
- EYLEA4U Patient Support Program: 1-855-EYLEA4U / 1-855-395-3248, Option 4, M–F 9 a.m.–8 p.m. ET
- Commercial Copay Card: as low as $0 copay per Eylea HD treatment for eligible commercially-insured patients (excluded for Medicare, Medicaid, federal program patients)
- Patient Assistance Program (PAP): free drug for uninsured / underinsured patients meeting income requirements
- Independent foundations: support for Medicare patients via foundations like Patient Access Network (PAN) and HealthWell — verify open funds quarterly
- Provider portal: eyleahdhcp.com for benefits investigation submission
Need to model what a specific patient will actually pay after copay assistance, deductible, coinsurance, and
OOP max? Run a CareCost Estimate — J0177 pre-loaded.
Phase 4
Fix problems
Step-therapy denials, NCCI denials, and laterality mismatches are the top three.
Common denials & how to fix them
| Denial reason | Common cause | Fix |
|---|---|---|
| Wrong J-code (J0178 instead of J0177) | Eylea HD billed under regular Eylea code | Verify formulation in chart. HD = J0177 × 8 units. Regular = J0178 × 2 units. |
| Step therapy not met | No documented bevacizumab trial; payer requires Avastin first | Submit bevacizumab trial documentation (3 doses, OCT measurements, response data) OR contraindication letter. |
| Bundled diagnostic (OCT/fundus photo) | 92134/92250 billed same day as 67028 without modifier | Resubmit OCT/fundus photo line with modifier XU or 59 + medical-record documentation showing distinct medical necessity. |
| Laterality mismatch | RT/LT modifier doesn't match the ICD-10 laterality character | Match: H35.3211 (right eye) → 67028-RT + J0177-RT. Same date, same eye on every line. |
| Bilateral billed as modifier 50 | Payer requires RT/LT separate lines, not modifier 50 | Resubmit as two lines: 67028-RT + 67028-LT, full fee on each. Same for J0177 drug lines. |
| NDC format | 10-digit NDC submitted instead of 11-digit; missing N4 qualifier | Use N461755005001ML0.07 format in CMS-1500 Box 24A shaded area. |
| JZ missing | Single-dose vial claim without JZ modifier | Resubmit with JZ on the J0177 line. Required since 7/1/2023. |
| Diagnosis not on payer's covered list | DR or RVO billed under a payer that hasn't updated post-Nov 2025 label expansion | Submit FDA label citation (Apr 2026 revision) + appeal. Some payer policies still list only wAMD/DME. |
Frequently asked questions
What is the HCPCS code for Eylea HD?
Eylea HD (aflibercept 8 mg high-dose) is billed under HCPCS J0177 — "Injection,
aflibercept hd, 1 mg." Each milligram equals one billable unit, so the standard 8 mg intravitreal dose is
billed as 8 units. The original Eylea 2 mg formulation uses a separate code: J0178. J0177
became a permanent J-code effective April 1, 2024, replacing the temporary code C9161.
How many units do I bill for an Eylea HD dose?
Bill 8 units of J0177 per Eylea HD injection. The drug comes in an 8 mg / 0.07 mL
single-dose vial; 1 mg = 1 unit; 8 mg = 8 units. A common biller error is billing 8 units of
J0178 (regular Eylea, 2 mg) for an Eylea HD dose — that denies because both the J-code
and the units are wrong.
What is the administration code for Eylea HD?
CPT 67028 — "Intravitreal injection of a pharmacologic agent (separate procedure)." Bill
67028 with an RT (right eye) or LT (left eye) modifier. For bilateral same-day injections, most payers require
two separate line items with RT and LT, full fee on each — not modifier 50. The administration code
must be billed on the same claim as the drug.
Can I bill 67028 with modifier 50 for bilateral Eylea HD injections?
Most payers, including Medicare, require two separate line items with RT and LT modifiers (one unit each, full fee on each line) — not modifier 50. Some commercial payers do accept 67028-50 with one unit and doubled fee. Verify with the specific payer before submission. Per AAPC, RT/LT is the safer default for retina coding.
Does Eylea HD require step therapy?
Often, yes — and this is a key difference from many specialty biologics. UnitedHealthcare requires documented trial of at least 3 doses of repackaged Avastin (bevacizumab) with minimal clinical response, or intolerance/contraindication to bevacizumab, before approving Eylea HD. Aetna's Medicare Part B program classifies Eylea HD as non-preferred (favoring bevacizumab and 2 mg aflibercept biosimilars). Commercial Aetna plans request bevacizumab trial documentation. Verify each payer.
What are the FDA-approved indications for Eylea HD?
As of the November 2025 supplement, four indications: neovascular (wet) age-related macular degeneration (wAMD), diabetic macular edema (DME), diabetic retinopathy (DR), and macular edema following retinal vein occlusion (RVO). Pediatric use is not established. DR and RVO indications are recent — payer policies may lag the FDA label.
What is the Medicare reimbursement for J0177?
Medicare Part B reimburses J0177 at ASP + 6%. Q2 2026 ASP+6% was
$301.177/mg, putting an 8 mg dose at approximately
$2,409.42 before sequestration. Sequestration (~2%) reduces actual paid to
roughly ASP + 4.3%. ASP is updated quarterly by CMS.
Does Eylea HD have biosimilars?
No. As of May 2026, no biosimilars exist for Eylea HD (8 mg). All approved aflibercept biosimilars (Yesafili/Q5155, Opuviz, Pavblu, Ahzantive, Enzeevu, Eydenzelt) reference the original Eylea 2 mg formulation only. This means commercial payers cannot direct patients toward a cheaper Eylea HD biosimilar — the only lower-cost ophthalmology anti-VEGF alternative is repackaged off-label bevacizumab (Avastin), which is what most payers' step-therapy rules push toward.
Are 67028 and OCT (92133/92134) bundled by NCCI?
Yes. NCCI bundles 67028 with 92133/92134 (OCT scans) and 92250 (fundus photography) when performed same-day.
To unbundle, append modifier XU or 59 to the bundled code with documented separate
medical necessity (e.g., the OCT informed a treatment decision distinct from the injection itself). Without
proper documentation and modifier, the bundled service will deny.
Reference
Sources & methodology
Every claim on this page is sourced. Methodology and review history below.
Source documents
- Regeneron — J-Code EYLEA HD Billing & Coding Brochure
- DailyMed — EYLEA HD (aflibercept) Prescribing Information
- FDA label PDF — Eylea HD 761355s010 (Nov 2025 supplement)
- Regeneron press release — Nov 2025 RVO + monthly dosing approval
- Regeneron press release — April 2026 5-month dosing approval (PULSAR/PHOTON 2-yr)
- CMS — Medicare Part B Drug ASP Pricing File
- CMS HCPCS Q4 2023 Application Summary
- CMS MCD Article A52451 — Aflibercept HD Billing & Coding
- UnitedHealthcare — Ophthalmologic VEGF Inhibitors policy
- Aetna CPB 0701 — VEGF Inhibitors for Ocular Indications
- Aetna Medicare Part B Eylea / Eylea HD criteria (2507-A)
- Blue Shield of California — Aflibercept (Eylea/Eylea HD) policy
- Retina Today — How to Create Clean Claims
- Retina Today — The Effect of Bilateral Rules on Retina Coding
- AAPC — CPT 67028
- CMS NCCI — National Correct Coding Initiative edit tables
- FDA — first interchangeable Eylea biosimilars (Yesafili, Opuviz)
About this page
We maintain this page as a living reference. Medicare ASP pricing is bound to our underlying CareCost data layer and refreshes automatically when CMS publishes new quarterly files. Coding and policy content is reviewed at least quarterly and updated whenever a source document changes.
Found an error? Email hello@carecostestimate.com.
Refresh cadence
| Element | Cadence | How it's refreshed |
|---|---|---|
| Medicare ASP pricing | Quarterly | Auto-bound to CareCost ASP layer; updates on CMS file release. |
| Payer policies (UHC, Aetna, BCBS) | Semi-annual | Manual review against published payer policy documents. |
| HCPCS / CPT / NCCI rules | Annual | Reviewed against CMS HCPCS quarterly files, AMA CPT releases, and NCCI edit updates. |
| NDC, dosing, FDA label | Event-driven | Tied to manufacturer document version + FDA label revision date. |
Reviewer
Pending SME review. This page is staff-authored from primary sources (FDA, CMS, manufacturer,
payer documents — all linked above). Final review by our SME, Catherine Rose (CPC), is in progress.
Until that review is complete, treat this as a draft reference and verify each cited source for high-stakes claims.
Change log
- — Initial publication. ASP data: Q2 2026. FDA label: April 2026 (incl. Nov 2025 DR/RVO additions and Apr 2026 5-month interval extension). Payer policies: UHC Ophth VEGF Inhibitors, Aetna CPB 0701 + MedB 2507-A, Blue Shield CA aflibercept (Apr 2024).
Methodology
Every claim on this page is sourced inline. Pricing reflects the current CMS Part B Drug ASP Pricing File. Payer policies are read directly from each payer's published medical policy documents. We do not paraphrase from billing-software vendor blogs. When manufacturer guidance and payer policy conflict (as happens with bilateral injection coding and step-therapy rules), we surface the conflict rather than picking a side.