Vabysmo (faricimab-svoa): J2777 billing, dosing and coverage

Vabysmo and the anti-VEGF family

9 products, 3 indications in common, 1 shared procedure code: faricimab is one of nine intravitreal therapies used for wet age-related macular degeneration, diabetic macular edema and macular edema after retinal vein occlusion. None of them carries an administration code of its own — all are reported with 67028 per eye — and their billing units are not interchangeable between products. Pricing comparison lives in Current Vabysmo pricing.

What Vabysmo is billed for

Vabysmo carries three FDA-labeled indications, each with its own ICD-10 code: neovascular (wet) age-related macular degeneration (H35.3210), diabetic macular edema (E11.311), and macular edema following retinal vein occlusion (H34.8110). Full dosing by indication is in Vabysmo dosing by indication below, and the eye-modifier billing reference is in Vabysmo billing reference.

Eylea (J0178)

Regeneron · aflibercept 2 mg. Billed per 1 mg rather than per 0.1 mg; an Eylea unit count and a Vabysmo unit count are not the same scale, and the two must never be converted against each other.

Eylea HD (J0177)

Regeneron · aflibercept 8 mg, a separate HCPCS code and a separate product from Eylea, not interchangeable on the claim.

Pavblu (Q5147)

Amgen · aflibercept-ayyh, the aflibercept biosimilar.

Lucentis (J2778)

Genentech · ranibizumab, billed per 0.1 mg like Vabysmo, but priced on its own ASP.

Cimerli (Q5128)

Sandoz · ranibizumab-eqrn, a ranibizumab biosimilar.

Byooviz (Q5124)

Biogen / Samsung Bioepis · ranibizumab-nuna, a ranibizumab biosimilar.

Beovu (J0179)

Novartis · brolucizumab-dbll.

Avastin, off-label (J9035)

Genentech · bevacizumab, repackaged for intravitreal use. It is the preferred step-therapy product at most payers that require one before Vabysmo, and it carries no patient-assistance programs on file for this indication.

Step therapy across the class

16 of 27 commercial faricimab policies require a preferred agent first, usually repackaged bevacizumab (Avastin). BCBS AR’s clinical-prerequisite rule reads: “Initial request must be for a preferred product. If initial request is not a preferred product, an administrative denial will be issued.” Vabysmo sits on that preferred list alongside Byooviz, Lucentis and Pavblu — ahead of Eylea, which is not.

Independence classifies faricimab as a Level 3 nonpreferred product, and its policy reads: “the nonpreferred product is eligible for coverage when the individual has documentation of a contraindication, intolerance” or inadequate response to a preferred product.

Regence stacks three tiers in order: “1. Treatment with a Level 1 product AND 2. Treatment with a Level 2 product AND 3. Treatment with a Level 3 product.”

Vabysmo dosing by indication

Every indication starts with monthly 6 mg loading doses, one injection per eye. What varies is how many loading doses and what happens after: the label lets the prescriber extend or shorten the interval based on optical coherence tomography (OCT) findings and visual acuity at each visit.

Warnings

Vabysmo carries no boxed warning. The label's contraindications and warnings are ocular and periocular infection, active intraocular inflammation, and hypersensitivity, with endophthalmitis, retinal detachment and a transient rise in intraocular pressure flagged as injection-related risks. Document the eye examined, any post-injection findings, and the interval since the prior dose in the chart at every visit.

Interval and duration

• Wet AMD: 6 mg every 4 weeks for 4 doses, then one of three OCT- and visual-acuity-guided regimens — weeks 28 and 44; weeks 24, 36 and 48; or weeks 20, 28, 36 and 44 — which work out to roughly every 16, 12 or 8 weeks.
• Diabetic macular edema: 6 mg every 4 weeks for at least 4 doses, then extended by up to 4 weeks at a time (or shortened by up to 8) on central subfield thickness and visual acuity, or a fixed 6 doses then every 8 weeks.
• Macular edema after RVO: 6 mg every 4 weeks, the highest visit count of the three indications; the label sets no interval extension for this indication.
• Treatment is open-ended: the label sets no stopping point, which is why commercial policies reauthorize on documented response rather than on a calendar. Two eyes are two separate treatment courses, each with its own laterality on the claim.

One vial per eye, always used in full

Vabysmo ships as a 6 mg single-dose vial or prefilled syringe (0.05 mL of 120 mg/mL solution), one container per eye, never shared or pooled across patients. Because the labeled dose is always the entire container, there is no partial-vial waste scenario: JZ applies to every J2777 line, and JW never appears on a Vabysmo claim. The eye-modifier arithmetic is in Vabysmo billing reference below.

Need the billing units for a patient? Convert dose to J2777 billing units →

Vabysmo billing reference

HCPCS — the tenth-of-a-milligram point

J2777 bills per 0.1 mg, not per mg. The 6 mg per-eye dose is 60 units. A claim billed as 6 units instead of 60 pays a tenth of the drug actually administered — the single most common Vabysmo billing error.

NDC

Two package types, each its own NDC: 50242-096-01 (single-dose vial) and 50242-096-77 (single-dose prefilled syringe). Pad the product segment to 11 digits for CMS-1500 Box 24A.

Administration: 67028 per eye, never 96372

The injection is the procedure, billed once per eye as 67028, because Vabysmo has no administration code of its own. 96372 is wrong on every intravitreal claim.

A complete one-eye claim has two lines: J2777 × 60 units with JZ and the eye modifier, and 67028 with the same eye modifier. A bilateral visit adds a second drug line for the other eye and reports 67028 once, with modifier 50, at 150% of the fee schedule rather than as two unmodified procedure lines. CMS's own label for 67028 is “intravitreal injection of a pharmacologic agent (separate procedure)”; the parenthetical distinguishes it from a service bundled into a more extensive procedure, not from an optional add-on, so it is reported on every Vabysmo claim.

Eye-modifier claim lines

The CMS Medically Unlikely Edit for J2777 is 120 units a day, two eyes at 60 units each; a same-day claim above that ceiling needs both eyes documented.

Modifiers

JZ: required on every Vabysmo claim line, because the single-dose container is always administered in full. RT / LT / 50: required on both the drug and procedure lines to identify which eye, or both, were injected.

Effective July 1, 2023, CMS requires the JZ modifier on all single-dose container claims when no drug is discarded. Because Vabysmo's labeled dose is always the entire 6 mg container, JW never applies — only JZ. Append modifier 25 to a same-day E/M code only if a significant, separately identifiable evaluation occurred beyond the routine pre-injection check-in, which is bundled into 67028.

Claim form

CMS-1500 / 837P (physician office; POS 11) field map for a J2777 claim.

Calculate units & the eye modifier →

Vabysmo coverage

• 18 of 27 commercial payer policy sets require prior authorization; 9 do not say clearly, so confirm those on the call
• 27 payers carry a faricimab policy, covering 201 individual rules: covered indication 79, clinical prerequisite 49, dosing 26, prior authorization 20, contraindication/exclusion 6, quantity limit 6, reauthorization 5, site of care 4, step-therapy reference 4, and combination rule 2
• 16 of 27 payers require another anti-VEGF product first, usually repackaged bevacizumab (Avastin); some, including BCBS AR, count Vabysmo itself as a qualifying preferred product, and others, including Independence, treat it as nonpreferred
• Reauthorization typically runs on documented clinical response rather than a fixed calendar: BCBS Michigan requires that “clinical documentation must be provided to confirm that current criteria are met and that the medication is providing clinical benefit,” and HMSA issues an initial approval for 3 months before requiring a measurable response
• Coverage counts vary by indication: diabetic macular edema is named in 26 of 27 policies, neovascular AMD and macular edema after RVO each in 25
• Payer dosing rules track the label closely: BCBS FL caps the dose at “6 mg to each eye every 4 weeks (28 days).” Among the corpus's 6 quantity-limit rules, BCBS MN's for each of the three indications reads “Administer 6 mg intravitreally per affected eye once every 4 weeks,” and UHC caps a single authorization at 12 months
• Preferred status is not always the last word: Excellus notes it is “designated as a preferred product; however, preferred status still requires prior use of a bevacizumab-containing product unless otherwise specified”

ICD-10 codes by indication

Use the most specific code supported by chart documentation. Each labeled indication has its own code.

Medicare carries no National Coverage Determination for faricimab; coverage runs through your MAC's intravitreal anti-VEGF Local Coverage Determination. See Medicare covered diagnoses for Vabysmo for the MAC-level detail.

Check the patient's actual policy: See Vabysmo coverage by payer →

Current Vabysmo pricing

Medicare ASP+6%: $31.322 / 0.1 mg · $1,879.32 / 6 mg. 60 units at $31.322 each prices the drug line at $1,879.32; add the $114.23 non-facility PFS allowance for 67028, and one eye totals $1,993.55 before the sequester, or $398.71 at 20% coinsurance.

Two eyes at the same visit price at $3,929.99 ($171.35 for 67028-50 in place of two unmodified lines), or $785.99 at 20%. Commercially, Aetna's all-states median is $33.43 per 0.1 mg unit, pricing 60 units at $2,005.80, and a rate appears in 36 of 36 payer files reviewed.

Sequestration reduces Medicare's 80% share by 2%. Commercial plans pay a contracted rate that differs by payer and state.

6 doses a year (6 mg per eye, four monthly doses then every 8 to 16 weeks) at $1,993.55 per dose — drug plus 67028 administration — total $11,961.30 before the sequester. That is the full annual drug-plus-administration cost for a patient staying on schedule, before benefits or assistance.

Billing basis matters as much as the headline rate: J2777, Q5128 and Q5124 price per 0.1 mg, while J0178, J0177, Q5147 and J0179 price per 1 mg. Reading a rate without its basis misstates the drug cost by a factor of ten.

Look up commercial reimbursement →

Patient cost

The patient's actual responsibility depends on: payer allowed rate · remaining Part B deductible ($283 in 2026) · benefits · − assistance · = patient responsibility. At 20% coinsurance with the deductible already met, a Medicare patient's share of one eye is roughly $398.71: $375.86 on the J2777 drug line and $22.85 on the 67028 procedure line. Injecting both eyes at the same visit brings the total coinsurance to $785.99: $375.86 per eye on the drug lines plus $34.27 on the 67028-50 line at 150%.

Calculate a Vabysmo patient estimate →

Copay & financial assistance

Two Genentech programs cover Vabysmo: the Genentech Ophthalmology Co-pay Program pays eligible commercial patients' drug and administration costs down to $0, up to $15,000 a year; the Genentech Patient Foundation provides the drug free to qualifying uninsured patients with household income under $150,000, with administration billed separately. Neither program applies to Medicare, Medicaid or other government insurance. Check current open/closed status before pointing a patient to either, since status changes without notice.

Five foundation funds on file cover Vabysmo. The Assistance Fund's Macular Degeneration fund is on file; check each fund's current status on the funds list. Four TotalAssist eye funds (macular degeneration, diabetic macular edema, diabetic retinopathy and retinal vein occlusion) take government insurance only; check each fund's current status on the funds list. See current Vabysmo assistance programs →

See current Vabysmo assistance programs →

Common Vabysmo denials & fixes