Page reviewed Aug 23, 2026 · from FDA-approved labeling (Drugs@FDA) — no drug-specific Medicare LCD
Quick answer
Medicare benefit
Part B (physician-administered)
FDA-indicated diagnoses
22 ICD-10 codes
Governing policy
FDA indications (no LCD)
Contractor (MAC)
Per medical necessity
Source
FDA labeling
Page reviewed
Aug 23, 2026
HCPCS codes covered:
J0179
J0179
No drug-specific Medicare coverage article exists for Beovu. Coverage is decided per medical necessity by your MAC. The FDA-approved indications below are the labeled uses Medicare generally pays for; an off-label use may be covered if supported by an approved compendium. Find your MAC by state →
What Medicare pays for Beovu (2026 Q3)
Once a claim carries a covered diagnosis, Medicare Part B reimburses the drug at the ASP + 6% payment limit. Current allowed amounts per billing unit:
| HCPCS | Description | Per unit | Allowed (ASP + 6%) |
|---|---|---|---|
| J0179 | Inj, brolucizumab-dbll, 1 mg | 1 mg | $359.713 |
Source: CMS ASP Drug Pricing File, 2026 Q3. Payment = ASP + 6% per unit; multiply by units billed (watch JZ/JW wastage). Your patient's share is typically 20% after the deductible. Estimate the full cost & patient out-of-pocket →
Beovu is a physician-administered biologic billed under Medicare Part B (not the Part D pharmacy benefit). Under Part B, Medicare pays the practice for the drug (HCPCS J0179) plus its administration — but only when the claim's diagnosis (ICD-10) code supports medical necessity. Each MAC publishes the specific covered diagnoses in a Billing & Coding Article; a claim with a diagnosis outside that list is typically denied as not medically necessary (CO-50).
Covered ICD-10 diagnoses for Beovu
The 22 FDA-approved indications for J0179, grouped by condition — filter to find a code.
Wet AMD (Neovascular AMD) — 4 diagnoses (applies to J0179)
Diseases of the eye & adnexa (4)
| ICD-10 | Covered diagnosis |
|---|---|
| H35.3210 | Exudative age-related macular degeneration, right eye, stage unspecified |
| H35.3220 | Exudative age-related macular degeneration, left eye, stage unspecified |
| H35.3230 | Exudative age-related macular degeneration, bilateral, stage unspecified |
| H35.3290 | Exudative age-related macular degeneration, unspecified eye, stage unspecified |
Diabetic Macular Edema (DME) — 18 diagnoses (applies to J0179)
Endocrine, nutritional & metabolic diseases (17)
| ICD-10 | Covered diagnosis |
|---|---|
| E11.311 | Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema |
| E11.3211 | Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye |
| E11.3212 | Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye |
| E11.3213 | Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral |
| E11.3219 | Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye |
| E11.3311 | Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye |
| E11.3312 | Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye |
| E11.3313 | Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral |
| E11.3319 | Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye |
| E11.3411 | Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye |
| E11.3412 | Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye |
| E11.3413 | Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral |
| E11.3419 | Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye |
| E11.3511 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye |
| E11.3512 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye |
| E11.3513 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral |
| E11.3519 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye |
Diseases of the eye & adnexa (1)
| ICD-10 | Covered diagnosis |
|---|---|
| H35.81 | Retinal edema |
What commercial payers require for Beovu
Medicare Part B is only half the answer — most Beovu claims are adjudicated by a commercial plan with its own medical policy. Below is what 24 commercial payers publish for Beovu, read from each payer's own policy document. 22 of 24 that state a position require prior authorization, and 1 run a site-of-care program that can push the infusion out of the hospital outpatient setting. 1 name a preferred product you must try or fail first.
| Payer | Prior auth | Preferred product first | Site of care | Indications named | Policy date |
|---|---|---|---|---|---|
| Aetna policy ↗ | Required | — | — | 2 | 2026-07-30 |
| Anthem / Elevance policy ↗ | Required | — | — | 2 | 2024-10-23 |
| Arkansas BCBS policy ↗ | Required | — | — | 2 | — |
| BCBS Kansas policy ↗ | Required | — | — | 2 | 2025-09-04 |
| BCBS Massachusetts policy ↗ | Required | — | Site-of-care program applies | 2 | 2026-03-15 |
| BCBS Michigan policy ↗ | Required | — | — | 1 | 2020-02-03 |
| BCBS Minnesota policy ↗ | Required | — | — | 2 | 2025-09-04 |
| BCBS South Carolina policy ↗ | Required | — | — | 2 | — |
| BCBS Tennessee policy ↗ | Required | — | — | 2 | 2025-09-09 |
| Blue Shield of California policy ↗ | Required | — | — | 2 | 2026-06-01 |
| Capital BlueCross policy ↗ | Required | — | — | 2 | 2025-09-04 |
| CareFirst BCBS policy ↗ | Required | — | — | 2 | — |
| Centene / Ambetter policy ↗ | Required | — | — | 2 | 2020-03-01 |
| Cigna policy ↗ | Required | — | — | 2 | 2026-03-01 |
| Excellus BCBS policy ↗ | Required | J0179 | — | 2 | 2026-07-02 |
| Florida Blue policy ↗ | Required | — | — | 1 | 2026-07-15 |
| HCSC (IL/TX/OK/NM/MT) policy ↗ | Not required | — | — | 2 | 2025-02-01 |
| Highmark BCBS policy ↗ | Required | — | — | 2 | 2026-07-01 |
| Horizon BCBS NJ policy ↗ | Required | — | — | 2 | 2025-09-04 |
| Independence Blue Cross policy ↗ | Not required | — | — | 2 | 2026-08-03 |
| Premera Blue Cross policy ↗ | Required | — | — | 2 | — |
| Regence BCBS policy ↗ | Required | — | — | 1 | 2026-01-22 |
| UnitedHealthcare policy ↗ | Required | — | — | 2 | 2026-07-01 |
| Wellmark BCBS policy ↗ | Required | — | — | 2 | 2026-01-01 |
What Beovu payers put in writing
Quoted from the medical policies linked above — 29 distinct requirements across 24 payers. These are the sentences an appeal has to answer.
Clinical prerequisites — what must be true before they pay
Patient is at least 18 years of age
— BCBS Kansas, Capital BlueCross policy ↗Therapy will not be used concomitantly with other ophthalmic vascular endothelial growth factor (VEGF) inhibitors
— BCBS Kansas, BCBS Minnesota policy ↗Prescribed by or in consultation with an ophthalmologist
— BCBS South Carolina, Centene / Ambetter policy ↗Individual has had a trial and inadequate response or intolerance to one preferred agent
— Anthem / Elevance policy ↗Documentation of contraindication, intolerance, or inadequate response (e.g., no improvement or maintenance in best corrected visual acuity [BCVA] or visual field or no reduction in the rate of vision decline) to bevacizumab (Avastin) or a bevacizumab biosimilar
— Florida Blue policy ↗Who are currently receiving the requested medication; AND • Who are experiencing benefit from therapy as evidenced by disease stability or disease improvement; AND • When dosing is in accordance with an authoritative source.
— HCSC (IL/TX/OK/NM/MT) policy ↗
Prior authorization
Prior authorization validity will be provided initially for 12 months.
— Capital BlueCross, Horizon BCBS NJ policy ↗When a drug is being reviewed for coverage under a member’s medical benefit plan or is otherwise subject to clinical review (including prior authorization)
— Anthem / Elevance policy ↗Prior Approval is required for Brolucizumab (e.g., Beovu), Aflibercept-abzv (e.g., Enzeevu), and Aflibercept-mrbb (e.g., Ahzantive).
— Arkansas BCBS policy ↗The initiation of aflibercept (Eylea, Eylea HD), aflibercept-ayyh (Pavblu), bevacizumab (including biosimilars), brolucizumab (Beovu)
— Florida Blue policy ↗Beovu (brolucizumab) * Covered under Medical Benefit Only, PA
— BCBS Massachusetts policy ↗Line of Business PA Required (Yes/No) BCBS Yes BCN Yes MAPPO Yes BCNA Yes
— BCBS Michigan policy ↗
Quantity and frequency limits
Authorization of 6 months may be granted for treatment of neovascular (wet) age-related macular degeneration.
— BCBS Tennessee, CareFirst BCBS policy ↗Authorization of 6 months may be granted for treatment of diabetic macular edema.
— BCBS Tennessee, CareFirst BCBS policy ↗6 mg per eye; each eye may be treated as frequently as every 8 weeks
— Anthem / Elevance policy ↗12 billable units every 28 days x 3 doses 12 billable units every 56-84 days
— BCBS Kansas policy ↗12 billable units every 42 days x 5 doses 12 billable units every 56-84 days
— BCBS Kansas policy ↗Administer 6 mg (0.05 mL of 120 mg/mL solution) by intravitreal injection per affected eye monthly (approximately every 25-31 days) for the first three doses, followed by 6 mg (0.05 mL) once every 8-12 weeks*.
— BCBS Minnesota policy ↗
Dosing rules
DME: 6 mg (1 vial) every 6 weeks for the first 5 doses, then every 8 to 12 weeks thereafter
— Centene / Ambetter policy ↗The dosing interval is not more frequent than once every 25 days for the first three doses, followed by not more frequently than once every 8 weeks for each eye being treated.
— Cigna policy ↗The dosing interval is not more frequent than once every 39 days for the first five doses, followed by not more frequently than once every 8 weeks for each eye being treated.
— Cigna policy ↗BOTH of the following (A and B): A) The dose is 6 mg administered by intravitreal
— Cigna policy ↗BROLUCIZUMAB-DBLL (BEOVU) Brolucizumab-dbll (Beovu) is supplied as a single-dose vial or single-dose prefilled syringe and is administered only by ophthalmic intravitreal injection as follows: Neovascular (wet or exudative) AMD: 6 mg intravitreal injection once monthly (approximately every 25–31 days) for the first three doses, followed by 6 mg injection every 8 to 12 weeks thereafter
— Independence Blue Cross policy ↗
Reauthorization / continuation
Prior authorization validity may be renewed every 12 months (365 days) thereafter.
— BCBS Kansas policy ↗Renewal Criteria: Maintenance or improvement of visual acuity [i.e. stabilization or gain of Snellen and/or ETDRS letters; stabilization or gain of ETDRS-DRSS score]
— BCBS Michigan policy ↗Renewal: Prior authorization validity may be renewed every 12 months thereafter.
— BCBS Minnesota policy ↗Yearly, based on continued response to therapy
— Blue Shield of California policy ↗Prior authorization validity may be renewed every 12 months thereafter.
— Capital BlueCross policy ↗Extended approvals are allowed if the patient continues to meet the Criteria and Dosing.
— Cigna policy ↗
Read from each payer's published medical policy between 2026-08-03 and 2026-08-13. Every requirement above is quoted from the policy it links to. Commercial policy changes without notice — confirm before you bill.
How to bill Beovu
Put a medically necessary, FDA-indicated diagnosis from the list above on the claim line with J0179. Matching codes, units and JZ/JW wastage →
Which policy governs Beovu
No drug-specific LCD or Article — see the note at the top of this page. Find your MAC → What an LCD, an Article and an NCD each govern →
If a claim for Beovu is denied
With no drug-specific Article, the usual cause is a diagnosis the MAC does not accept as medically necessary for J0179, or an off-label use with no compendium support. The five denial patterns and how to fix each →
Frequently asked questions
- Is Beovu covered by Medicare?
- Yes. Beovu (J0179) is covered under Medicare Part B as a physician-administered drug when billed for a medically necessary indication. There is no drug-specific Local Coverage Determination (LCD) for it, so coverage is determined per medical necessity by your MAC; the FDA-approved indications below are the starting point.
- What diagnoses are covered for Beovu (J0179)?
- Medicare publishes no drug-specific covered-diagnosis list for J0179. The 22 ICD-10 codes here are the FDA-approved indications; an off-label use needs approved-compendium support (DrugDex, NCCN) to be payable.
- Which Medicare policy covers Beovu?
- No drug-specific LCD or Billing & Coding Article exists for Beovu. It's covered under the general Medicare Part B drug benefit per medical necessity, as judged by your Medicare Administrative Contractor (MAC).
- Why was my Beovu claim denied as not medically necessary?
- The most common cause is a diagnosis the MAC doesn't consider medically necessary for J0179. Bill a covered/FDA-approved indication from the list below, document medical necessity, and confirm any local guidance with your MAC.
Related references
Covered is only half the answer.
You know the diagnosis is payable. Now quote the patient before the visit and catch underpayments: get Beovu's exact Medicare allowed amount, your payer's rate vs. ASP+6%, and the patient's out-of-pocket — in about 30 seconds, free.
Estimate Beovu cost & patient owe →Source & verification
- Source
- FDA-approved indications (Drugs@FDA labeling) mapped to ICD-10-CM. No drug-specific Medicare LCD/Article exists for Beovu — Part B coverage is determined per medical necessity by your MAC.
- Primary sources
- DailyMed — Beovu prescribing information · CMS Part B Drug ASP Pricing File — the quarterly payment limit quoted above · CMS Medicare Coverage Database — searched for “Beovu”; no drug-specific NCD, LCD or Billing & Coding Article exists, which is why the FDA-indicated codes above are the working list
- Page last reviewed by CareCost
- Aug 23, 2026 (coverage data retrieved 2026-08-26; we re-verify against CMS quarterly).
- Code licensing
- ICD-10-CM codes are public domain (CMS/CDC). CPT® codes are AMA-copyrighted and are intentionally not listed here — see the administration-code reference for those.
- Not advice
- This is general billing reference, not legal or billing advice. Always verify against the LCD/Article that applies to your MAC and patient.
- How we build this
- Compiled programmatically from the CMS Coverage API under a founder-led methodology maintained by Erin Rose (Founder), and reviewed against the source article with a practitioner-correction loop. See our methodology and editorial policy.
- Spotted an error?
- Email editorial@carecostestimate.com.