Priority Health: Eylea HD Payer Policy

Created by C. Denise Burrell, Modified on Wed, 8 Jan at 5:56 PM by C. Denise Burrell

Priority Health: Eylea HD Payer Policy (Beta Access)

TABLE OF CONTENTS

MEDICARE PART B

HCPCS code(s): J0177
Precertification required?: Yes - Dependent (Click here to view)
Step therapy required: Not Specified
Provider fax form: Eylea HD Fax Form (✅ Available in SamaCare)
FDA-Approved Indications: Not Specified
Recommended Dose: Not Specified

Other Pertinent Information:

Prior Authorization Requirements:

No Prior Authorization is required when billed with the following ICD-10 diagnoses: All other ICD-10 diagnoses: Prior Authorization is required
A18.53, E08.311, E08.319, E08.3211 - E08.3213, E08.3291 - E08.3293, E08.3311 - E08.3313, E08.3391 - E08.3393, E08.3411 - E08.3413, E08.3491 - E08.3493, E08.3511 - E08.3513, E08.3521 - E08.3523, E08.3531 - E08.3533, E08.3541 - E08.3543, E08.3551 - E08.3553, E08.3591 - E08.3593, E09.311, E09.319, E09.3211 - E09.3213, E09.3291 - E09.3291, E09.3311 - E09.3313, E09.3391 - E09.3393, E09.3411 - E09.3413, E09.3491 - E09.3493, E09.3511 - E09.3513, E09.3521 - E09.3523, E09.3531 - E09.3533, E09.3541 - E09.3543, E09.3551 - E09.3553, E09.3591 - E09.3593, E10.311, E10.319, E10.3211 - E10.3213, E10.3291 - E10.3293, E10.3311 - E10.3313, E10.3391 - E10.3393, E10.3411 - E10.3413, E10.3491 - E10.3493, E10.3511 - E10.3513, E10.3591 - E10.3599, E11.3211-E11.3219, E11.3291-E11.3299, E11.3311- E11.3313, E11.3391 - E11.3393, E11.3411- E11.3413, E11.3491 - E11.3493, E11.3511 - E11.3513, E11.3521 – E11.3523, E11.3531 – E11.3533, E11.3541 – E11.3543, E11.3551 – E11.3553, E11.3591 – E11.3593, E13.311, E13.319, E13.3211- E13.3213, E13.3291 - E13.3293, E13.3311- E13.3313, E13.3391 - E13.3393, E13.3411-E13.3413, E13.3491 - E13.3493, E13.3511- E13.3513, E13.3521 – E13.3523, E13.3531 – E13.3533, E13.3541 – E13.3543, E13.3551 – E13.3553, E13.3591 – E13.3593, H34.8110, H34.8120, H34.8130, H34.8190, H34.8310, H34.8320, H34.8330, H34.8390, H35.051 - H35.053, H35.101 – H35.169, H35.3210 - H35.3233, H35.351 – H35.353

No Prior Authorization is required when billed with the following ICD-10 diagnoses:

All other ICD-10 diagnoses: Prior Authorization is required

A18.53, E08.311, E08.319, E08.3211 - E08.3213, E08.3291 - E08.3293, E08.3311 - E08.3313, E08.3391 - E08.3393, E08.3411 - E08.3413, E08.3491 - E08.3493, E08.3511 - E08.3513, E08.3521 - E08.3523, E08.3531 - E08.3533, E08.3541 - E08.3543, E08.3551 - E08.3553, E08.3591 - E08.3593, E09.311, E09.319, E09.3211 - E09.3213, E09.3291 - E09.3291, E09.3311 - E09.3313, E09.3391 - E09.3393, E09.3411 - E09.3413, E09.3491 - E09.3493, E09.3511 - E09.3513, E09.3521 - E09.3523, E09.3531 - E09.3533, E09.3541 - E09.3543, E09.3551 - E09.3553, E09.3591 - E09.3593, E10.311, E10.319, E10.3211 - E10.3213, E10.3291 - E10.3293, E10.3311 - E10.3313, E10.3391 - E10.3393, E10.3411 - E10.3413, E10.3491 - E10.3493, E10.3511 - E10.3513, E10.3591 - E10.3599, E11.3211-E11.3219, E11.3291-E11.3299, E11.3311- E11.3313, E11.3391 - E11.3393, E11.3411- E11.3413, E11.3491 - E11.3493, E11.3511 - E11.3513, E11.3521 – E11.3523, E11.3531 – E11.3533, E11.3541 – E11.3543, E11.3551 – E11.3553, E11.3591 – E11.3593, E13.311, E13.319, E13.3211- E13.3213, E13.3291 - E13.3293, E13.3311- E13.3313, E13.3391 - E13.3393, E13.3411-E13.3413, E13.3491 - E13.3493, E13.3511- E13.3513, E13.3521 – E13.3523, E13.3531 – E13.3533, E13.3541 – E13.3543, E13.3551 – E13.3553, E13.3591 – E13.3593, H34.8110, H34.8120, H34.8130, H34.8190, H34.8310, H34.8320, H34.8330, H34.8390, H35.051 - H35.053, H35.101 – H35.169, H35.3210 - H35.3233, H35.351 – H35.353

Continuation Criteria - Not Specified

COMMERCIAL

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

MEDICAID

HCPCS code(s): J0177
Precertification required?: Yes - (Click here for full policy)
Step therapy required: Dependent (Click here for full policy)
Provider fax form: Eylea HD Fax Form (✅ Available in SamaCare)
FDA-Approved Indications:
Recommended Dose:
Other Pertinent Information
- Initial Approval Criteria
- Continuation Criteria