Codes & NDC
| HCPCS | J0177 — "Inj, aflibercept hd, 1 mg" (permanent, eff. 4/1/2024; replaced temp C9161) |
|---|
| NDC | 61755-050-01 (10) / 61755-0050-01 (11) — N4 qualifier + ML + 0.07 |
|---|
| Vial | 8 mg / 0.07 mL of 114.3 mg/mL solution |
|---|
| Route | Intravitreal injection |
|---|
| Benefit | Medical (provider buy-and-bill); not specialty pharmacy |
|---|
Year-1 unit math (wAMD example)
| Month | Visits | Units |
|---|
| Loading (months 0–2) | 3 monthly @ 8 mg | 3 × 8 = 24 |
| Maintenance (months 3–12) | ~5 visits @ Q8–16W | ~5 × 8 = 40 |
| Total year 1 per eye | ~8 doses | ~64 units J0177 |
DR/RVO: similar Q4W loading then less frequent. Per-eye math; double for bilateral.
Dosing per indication
| Indication | Schedule |
|---|
| wAMD | Q4W × 3, then Q8–16W (up to 20W after yr 1) |
| DME | Q4W × 3, then Q8–16W (up to 20W after yr 1) |
| DR | Q4W × 3, then Q8–12W (added Nov 2025) |
| RVO | Q4W × 3–5, then Q8W (added Nov 2025) |
Pediatric: safety not established. No payer covers pediatric.
Bilateral billing (RT/LT, not -50)
Most payers require two separate lines for bilateral same-day:
- Line 1:
67028-RT + J0177-RT 8 units
- Line 2:
67028-LT + J0177-LT 8 units
Some commercial payers accept 67028-50 (1 unit, fee × 2). Verify per payer.
Modifiers
| Mod | When |
|---|
RT / LT | Required on both J0177 and 67028 lines |
JZ | Required when no drug discarded (typical) |
JW | Only if ≥1 mg wasted (rare) |
25 | On E/M when separately identifiable |
XU / 59 | To unbundle OCT/fundus photo from 67028 |
NCCI bundling alert
67028 bundles with these same-day services unless modifier + documentation:
| Code | Service |
|---|
92133 / 92134 | OCT — bundled |
92250 | Fundus photo — bundled |
99211–99215 | E/M — bundled (use mod 25) |
92012 / 92014 | Eye visit — not bundled |
Common denial: OCT same-day as 67028 without XU/59 + documentation.
ICD-10 (most common)
| Code | For |
|---|
H35.32xx | Wet AMD (5th/6th char = laterality + stage) |
E11.341x / E10.341x | DME in T2DM / T1DM |
E11.351x | PDR + DME in T2DM |
E11.331x / E11.321x | Mod / Mild NPDR with DME |
H34.81xx / H34.83xx | CRVO / Branch RVO |
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 — ≥3 doses bevacizumab |
| Aetna commercial | Yes | Yes — bevacizumab trial requested |
| Aetna Medicare Part B | Yes | Non-preferred (favors bevacizumab + 2 mg biosimilars) |
| BCBS (most plans) | Yes | Yes (verify per plan) |
Step therapy is the dominant Eylea HD UM lever. Document 3+ bevacizumab doses, OCT response data, OR contraindication before requesting auth.
Medicare reimbursement (Q2 2026)
| Field | Value |
|---|
| ASP + 6% | $301.177 / mg (effective 4/1 – 6/30/2026) |
| 8 mg dose | $2,409.42 (8 units × $301.177) |
| After ~2% sequestration | ~$2,361 (actual paid) |
| NCD/LCD | None drug-specific; MAC article A52451 |
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-codes, no G-codes — intravitreal must be in-office or ASC.
Patient assistance — EYLEA4U
- Phone: 1-855-EYLEA4U / 1-855-395-3248, Option 4 (M–F 9–8 ET)
- Commercial copay: as low as $0/treatment (excludes Medicare/Medicaid)
- PAP: free drug for uninsured/underinsured
- Medicare patients: verify open foundation funds (PAN, HealthWell)
- Provider portal: eyleahdhcp.com
Different drug, different code: Regular Eylea = J0178, NDC 61755-005, 2 mg / 2 units. Common denial: 8 units of J0178 for an HD dose. Verify formulation in chart before billing.