Aetna: Eylea HD Payer Policy (Beta Access)

TABLE OF CONTENTS 

• Medicare Part B
• Commercial 

MEDICARE PART B

• HCPCS code(s): J0177
• Precertification required?: Yes - (Click here for full policy)
• Step therapy required: Yes - (Click here for full policy)
• Provider fax form: Eylea HD Fax Form (✅ Available in SamaCare) 
• FDA-Approved Indications: 

• Recommended Dose: Not Provided
• Other Pertinent Information:
  • Initial Approval Criteria:
    
  • Continuation Guidelines:

COMMERCIAL

• HCPCS code(s): J0177
• Precertification required?: Yes - (Click here for full policy)
• Step therapy required: Not Provided
• Provider fax form: Eylea HD Fax Form (✅ Available in SamaCare) 
• FDA-Approved Indications: 
  
• Recommended Dose:
• Other Pertinent Information:
  • Initial Approval Criteria
    
  • Continuation Criteria