Aetna: Eylea Payer Policy (Beta Access)

TABLE OF CONTENTS

• Medicare Part B 
• Commercial

Medicare Part B 

• HCPCS code(s): J0178
• Precertification required?: Yes (Click here for full policy)
• Step therapy required: Yes (Click here for full policy)
• Provider fax form: Eylea Fax Form (✅ Available in SamaCare) 
• FDA-Approved Indications:
  • 
• Recommended Dose: Not Provided
• Other Pertinent Information: 
  • For initial approval, authorization of 12 months may be granted for all indications.  
  • For continuation of therapy:
    • 

Commercial

• HCPCS code(s): J0178
• Precertification required?: Yes (Click here for full policy)
• Step therapy required: Not Provided
• Provider fax form: Eylea Fax Form (✅ Available in SamaCare) 
• FDA-Approved Indications:

  • 

• Recommended Dose:

  • 

• Other Pertinent Information: 

  • 

We're here to guide you through your prior authorization quest!