ICD-10 (most common)
| Code | For |
|---|
H35.32xx | Wet AMD (laterality + stage) |
E11.311 / E11.319 | T2DM with DR / unspec, with or without ME |
E10.311 / E10.319 | T1DM equivalents |
E11.359 / E10.359 | DM with PDR (use specific severity char) |
H34.81xx / H34.83xx | CRVO / BRVO with macular edema |
H44.2x + H35.05 | Degenerative myopia + retinal neovasc (mCNV) |
H35.10–H35.17 | ROP by zone & stage |
H35.81 | Retinal edema (adjunct only) |
Match laterality. ICD-10 5th-char laterality must match RT/LT modifier.
Payer requirements (May 2026)
| Payer | PA | Step / Preference |
|---|
| UnitedHealthcare | Yes | Yes — bevacizumab first; biosimilar (Q5124/Q5128) preferred over reference Lucentis |
| Aetna commercial | Yes | Bevacizumab trial; Cimerli/Byooviz preferred |
| BCBS (most plans) | Yes | Bevacizumab trial; many require biosimilar substitution |
Most-stepped anti-VEGF in 2026: three-front squeeze — Avastin ($50–100), biosimilars 30–40% cheaper, two interchangeable products allow pharmacy substitution.
Medicare reimbursement (Q2 2026)
| Field | Value |
|---|
| ASP + 6% (J2778) | $67.853 / 0.1 mg unit (effective 4/1 – 6/30/2026) |
| 0.5 mg dose (5 units) | $339.27 |
| 0.3 mg dose (3 units) | $203.56 |
| After ~2% sequestration | ~ASP+4.3% actual paid |
| Biosimilar Q5124 / Q5128 | Reimbursed at biosimilar ASP+6% of reference (typically 30–40% lower) |
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 — Genentech Access Solutions
- Genentech Ophthalmology Co-pay Program (EyeOnCopay): as low as $0/treatment for commercial patients
- Annual cap: up to $15,000/year for drug; no income requirement
- Excluded: Medicare, Medicaid, VA, DoD, TRICARE
- Enrollment: (855) 218-5307 · eyeoncopay.com
- Genentech Patient Foundation: free Lucentis for uninsured/underinsured
- Medicare patients: verify HealthWell Macular Degeneration Fund & PAN quarterly
Warnings & Precautions
- Endophthalmitis & retinal detachments from intravitreal injection — aseptic technique
- Increased IOP within 60 min of injection
- Arterial thromboembolic events (stroke, MI, vascular death)
- Fatal events reported in DME/DR populations (post-marketing)
Different drug, different code: Susvimo (port delivery, ranibizumab) = J2779 — not Lucentis. Same molecule, different presentation, different code/admin (insertion CPT, not 67028).