Eylea (aflibercept)
Billing
Code: J0178
Description: Aflibercept injection
Unit: 1 mg
Payment: $898.327
Pay quarter: Q1 2023
Dosage and Frequency
Neovascular (Wet) Age-Related Macular Degeneration (AMD)
Induction:
• 2mg IVT every 1 month for the first 3 months
Maintenance:
• 2mg IVT every 2 months
Induction:
• 2mg IVT every 1 month for the first 3 months
Maintenance:
• 2mg IVT every 2 months
Macular Edema Following Retinal Vein Occlusion (RVO)
• 2mg IVT every 1 month
• 2mg IVT every 1 month
Diabetic Macular Edema (DME)
Diabetic Retinopathy (DR)
Induction:
• 2mg IVT every 1 month for the first 5 injections
Maintenance:
• 2mg IVT every 2 months
Diabetic Retinopathy (DR)
Induction:
• 2mg IVT every 1 month for the first 5 injections
Maintenance:
• 2mg IVT every 2 months
Calculate drug reimbursement
Total Reimbursement:
$1,904.45(ASP: $1,796.65, Margin: $107.80)
Code:
J0178# Units to bill:
2Prior Authorization
Prior auth criteria for Eylea may include but is not limited to:
1. Patient must have been diagnosed with neovascular age-related macular degeneration (AMD).
2. All other anti-VEGF treatments (e.g. ranibizumab, aflibercept) must have been tried and failed, or not tolerated.
3. Patient must have evidence of active choroidal neovascularization (CNV), with fluid or lipid present on optical coherence tomography (OCT).
4. The patient must have an active lesion (with fluid or lipid present on OCT) at the time of treatment initiation.
5. The patient must be at least 18 years of age.
6. The patient must have an intraocular pressure (IOP) of less than 22 mmHg.
7. The patient must have a best-corrected visual acuity (BCVA) of 35 letters or worse on the Early Treatment Diabetic Retinopathy Study (ETDRS) chart.
8. The patient must have adequate kidney function as determined by creatinine clearance or estimated glomerular filtration rate (eGFR).
Insurance prior auth guidelines:
Billable NDCs
61755-0005-01
Eylea (REGENERON PHARMACEUTICALS INC.)
2 MG
61755-0005-02
EYLEA (REGENERON PHARMACEUTICALS INC.)
2 MG
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