Eylea (J0178): Medicare covered diagnoses & ICD-10 codes

What Medicare pays for Eylea (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:

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 →

Eylea 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 J0178) 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 Eylea

The 224 codes below are the diagnoses Wellpoint Federal accepts for J0178 under Article A52451, grouped exactly as CMS groups them and organized by condition category for scanning. Use the filter in each group to find a specific code or condition.

What commercial payers require for Eylea

Medicare Part B is only half the answer — most Eylea claims are adjudicated by a commercial plan with its own medical policy. Below is what 28 commercial payers publish for Eylea, read from each payer's own policy document. 24 of 28 that state a position require prior authorization, and 5 run a site-of-care program that can push the infusion out of the hospital outpatient setting. 7 name a preferred product you must try or fail first.

What Eylea payers put in writing

Quoted from the medical policies linked above — 24 distinct requirements across 28 payers. These are the sentences an appeal has to answer.

Clinical prerequisites — what must be true before they pay

• Member is a premature infant with a maximum gestational age at birth of 32 weeks OR a birth weight of ≥ 800 to 1500 g— BCBS Kansas, BCBS Minnesota, Capital BlueCross policy ↗
• Therapy will not be used concomitantly with other ophthalmic vascular endothelial growth factor (VEGF) inhibitors— BCBS Kansas, BCBS Minnesota, Capital BlueCross policy ↗
• Patient must have a contraindication, intolerance, or failure to a bevacizumab product prior to the consideration of another ophthalmic VEGF-inhibitor product— BCBS Kansas, BCBS Minnesota policy ↗
• Member is at least 18 years of age, unless otherwise specified— BCBS Kansas, BCBS Minnesota policy ↗
• Treatment with bevacizumab or a bevacizumab biosimilar has been ineffective, not tolerated or contraindicated— BCBS Michigan, BCBS Mississippi policy ↗
• Individual has had a trial and inadequate response or intolerance to one preferred agent— Anthem / Elevance policy ↗

Prior authorization

• 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 ↗
• Effective January 1, 2026, Prior Approval is required for a Aflibercept (e.g., Eylea)— Arkansas BCBS policy ↗
• Prior approval is required to ensure the safe, clinically appropriate, and cost-effective use of VEGF Inhibitors— BCBS Federal Employee Program policy ↗
• Approval duration: 1 year (except retinopathy of prematurity— Florida Blue policy ↗
• Eylea * Covered under Medical Benefit Only, PA Prior Authorization required— BCBS Massachusetts policy ↗
• Requests must be supported by submission of chart notes and patient specific documentation.— BCBS Michigan policy ↗

Quantity and frequency limits

• 2 mg per eye; each eye may be treated as frequently as every 4 weeks— Anthem / Elevance policy ↗
• Retinopathy of prematurity: 0.4 mg per eye; each eye may be treated as frequently as every 10 days— Anthem / Elevance policy ↗
• 4 units (4 mg) every 28 days x 3 doses 4 units (4 mg) every 28 days 16 units (16 mg) every 25 days x 3 doses 16 units (16 mg) every 25 days— BCBS Kansas policy ↗
• 4 unit (4 mg) x 1 dose 4 units (4 mg) every 10 days x 2 doses— BCBS Kansas policy ↗
• Quantity Limits: Align with FDA recommended dosing— BCBS Michigan policy ↗
• Authorization Period: For at least 60 days and up to one year at a time— BCBS Michigan policy ↗

Dosing rules

• The recommended dose of Aflibercept (e.g., Eylea) for age-related macular degeneration, diabetic macular edema, diabetic retinopathy, macular edema following retinal vein occlusion and choroidal neovascularization due to presumed ocular histoplasmosis syndrome is 2 milligram per eye— Arkansas BCBS policy ↗
• Opuviz, Pavblu, and Yesafili Only Administer 0.4 mg intravitreally per affected— BCBS Minnesota policy ↗
• Pavblu, and Yesafili Only Initiation: Administer 2 mg intravitreally per affected— BCBS Minnesota policy ↗
• Eylea Neovascular (wet) age related macular degeneration:  2 mg administered via intravitreal— BCBS Nebraska policy ↗
• (wet) AMD. The recommended dose for EYLEA ™ is 2 mg (0.05 mL) administered by— BCBS South Carolina policy ↗
• Not to exceed 2 mg given by intravitreal injection every 25 days— Blue Shield of California 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 Eylea

Put the patient's covered ICD-10 diagnosis on the claim line with J0178. Matching codes, units and JZ/JW wastage →

Which policy governs Eylea

The covered code lists live in Article A52451 (tied to LCD L33394) — CMS moved code lists out of LCDs and into Articles, which is why the diagnoses live in the Article. What an LCD, an Article and an NCD each govern →

If a claim for Eylea is denied

The usual cause is a diagnosis outside Article A52451's covered list, or a product code and unit count that do not match what was given. The five denial patterns and how to fix each →