By Counterforce Health Team in Eylea / Lucentis (aflibercept / ranibizumab) —

How to Get Eylea and Lucentis Covered by Cigna in Ohio: Complete Coding, Appeals, and Authorization Guide

Answer Box: Getting Eylea/Lucentis Covered by Cigna in Ohio

Cigna requires prior authorization for Eylea (aflibercept) and Lucentis (ranibizumab) in Ohio, typically mandating bevacizumab (Avastin) step therapy first. Submit PA requests via CoverMyMeds or fax to 1-866-873-8279 with complete ICD-10 codes (H35.32_ for wet AMD, E11.3_ for diabetic conditions), OCT/FFA imaging, and documented bevacizumab failure or contraindication. If denied, you have 180 days to request Ohio external review through an Independent Review Organization. Start today: Call your retina specialist to confirm diagnosis documentation and initiate the prior authorization process.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit Paths
  2. ICD-10 Mapping for Eye Conditions
  3. HCPCS J-Codes and Units Billing
  4. Clean Prior Authorization Request
  5. Common Coding Pitfalls
  6. Cigna Verification Resources
  7. Appeals Process in Ohio
  8. Pre-Submission Audit Checklist
  9. FAQ: Cigna Coverage in Ohio

Coding Basics: Medical vs. Pharmacy Benefit Paths

Eylea and Lucentis are typically covered under Cigna's medical benefit when administered as intravitreal injections in physician offices or outpatient facilities. This means billing through HCPCS J-codes rather than pharmacy NDC numbers.

Medical Benefit Coverage

  • J0178 (Eylea/aflibercept): 1 mg per unit
  • J2778 (Lucentis/ranibizumab): 0.1 mg per unit
  • CPT 67028: Intravitreal injection administration
  • Requires prior authorization through Cigna's medical PA process

When Pharmacy Benefit Applies

Rarely, compounded formulations or specific plan designs may route these drugs through pharmacy benefits. Always verify with Cigna member services at 1-800-882-4462 before assuming coverage pathway.

ICD-10 Mapping for Eye Conditions

Accurate ICD-10 coding is critical for Cigna approval. The codes must specify laterality (which eye) and disease stage or activity level.

Wet AMD Codes

  • H35.321_: Right eye exudative AMD
  • H35.322_: Left eye exudative AMD
  • H35.323_: Bilateral exudative AMD
  • Seventh digit staging:
    • 1: Active choroidal neovascularization
    • 2: Inactive CNV (involuted/regressed)
    • 3: Inactive scar

Example: H35.3221 = Left eye wet AMD with active CNV

Diabetic Eye Disease Codes

  • E11.3211: Type 2 DM with mild NPDR with macular edema, right eye
  • E11.3513: Type 2 DM with proliferative DR with macular edema, bilateral
  • E10.37x3: Type 1 DM with diabetic macular edema, resolved following treatment, bilateral
Documentation Tip: Chart notes must explicitly state laterality and disease activity. "Bilateral wet AMD with active CNV" supports H35.3231, while vague documentation like "macular degeneration" may trigger denials.

HCPCS J-Codes and Units Billing

Eylea (J0178) Billing

  • 1 unit = 1 mg aflibercept
  • Standard 2 mg dose = 2 units
  • Use JW modifier for documented drug wastage when appropriate

Lucentis (J2778) Billing

  • 1 unit = 0.1 mg ranibizumab
  • Standard 0.3 mg dose = 3 units
  • 0.5 mg dose = 5 units

Administration Coding

CPT 67028 covers the injection procedure itself. Bill one unit per eye treated, regardless of drug quantity administered.

Coverage at a Glance

Requirement Eylea (J0178) Lucentis (J2778) Source
Prior Authorization Required Required Cigna PA List
Step Therapy Bevacizumab first Bevacizumab first Cigna Step Therapy Policy
Dosing Interval Minimum 28 days Minimum 28 days Cigna Medical Policy
Specialty Required Ophthalmology/Retina Ophthalmology/Retina Standard practice

Clean Prior Authorization Request

A complete PA request includes five essential elements:

1. Patient Demographics

  • Full name, DOB, Cigna member ID
  • Prescribing physician NPI and specialty
  • Diagnosis with specific ICD-10 codes

2. Clinical Documentation

  • Recent OCT and FFA imaging results
  • Visual acuity measurements (both eyes)
  • Disease severity and progression risk
  • Treatment goals and expected outcomes

3. Prior Treatment History

  • Documented bevacizumab trial with:
    • Dates of administration
    • Number of injections given
    • Response or lack thereof
    • Reason for discontinuation
  • OR clear contraindication to bevacizumab

4. Medical Necessity Justification

Reference current clinical guidelines:

  • American Academy of Ophthalmology Preferred Practice Patterns
  • FDA-approved labeling for specific indication
  • Peer-reviewed literature supporting treatment choice

5. Prescription Details

  • Drug name, strength, quantity
  • Dosing frequency and duration
  • Site of administration
  • NDC/J-code information

Submit via:

  • CoverMyMeds portal (preferred)
  • Fax: 1-866-873-8279
  • Phone: 1-800-882-4462 for urgent requests

Common Coding Pitfalls

Unit Conversion Errors

  • Mistake: Billing Lucentis 0.3 mg as 1 unit instead of 3 units
  • Fix: Always divide total mg by the per-unit amount (0.1 mg for J2778)

Mismatched Diagnosis Codes

  • Mistake: Using H35.329 (unspecified eye) when chart clearly documents right eye involvement
  • Fix: Review documentation to specify exact laterality and stage

Missing Step Therapy Documentation

  • Mistake: Requesting Eylea without bevacizumab trial history
  • Fix: Include detailed prior treatment summary or contraindication rationale

Incorrect Administration Coding

  • Mistake: Billing multiple units of 67028 for bilateral injections
  • Fix: Use 67028 with appropriate modifiers (RT/LT or 50 for bilateral)

Cigna Verification Resources

Before submitting any request, verify current requirements:

Online Resources

Phone Verification

  • Provider Services: 1-800-882-4462
  • Member Services: Number on back of insurance card
  • Express Scripts: 1-800-753-2851 for specialty drugs

Required Information for Verification

  • Patient's Cigna member ID and group number
  • Specific drug name and NDC/J-code
  • Prescribing physician information
  • Planned site of administration

Appeals Process in Ohio

If Cigna denies your prior authorization, Ohio law provides a structured appeals pathway with specific timelines and rights.

Internal Appeals (Required First Step)

  • Timeline: Submit within 180 days of denial
  • Method: Written request to Cigna
  • Response time: 30 days for standard, 72 hours for urgent
  • Required: Include all supporting clinical documentation

External Review Through Ohio Department of Insurance

After exhausting internal appeals, Ohio residents can request an Independent Review Organization (IRO) evaluation:

  • Eligibility: Medical necessity denials or "experimental/investigational" determinations
  • Timeline: 180 days from final Cigna denial to request external review
  • Process: Submit written request to Cigna, who forwards to Ohio DOI
  • Decision timeframe: 30 days standard, 72 hours expedited
  • Binding: IRO decision is legally binding on Cigna

Ohio Department of Insurance Contact

  • Consumer Hotline: 1-800-686-1526
  • Website: insurance.ohio.gov
  • External Review Form: Available on ODI website
From Our Advocates: We've seen many Cigna anti-VEGF denials overturned when the appeal includes comprehensive imaging documentation and peer-reviewed evidence supporting the specific agent requested over bevacizumab. The key is demonstrating why the standard step therapy protocol isn't appropriate for this patient's clinical situation.

Pre-Submission Audit Checklist

Before submitting your PA request, verify each element:

Clinical Documentation ✓

  • ICD-10 codes specify laterality and disease stage
  • Recent OCT and FFA reports included
  • Visual acuity documented for both eyes
  • Treatment history clearly outlined

Step Therapy Compliance ✓

  • Bevacizumab trial documented with dates and outcomes
  • OR contraindication to bevacizumab clearly stated
  • Medical necessity for specific agent justified

Coding Accuracy ✓

  • Correct J-code selected (J0178 vs J2778)
  • Units calculated properly based on dosage
  • Administration code (67028) included appropriately

Submission Details ✓

  • All required forms completed
  • Prescriber NPI and specialty verified
  • Patient demographics match insurance card exactly
  • Supporting literature attached if needed

Counterforce Health Support

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters, identifies the specific denial basis, and drafts point-by-point rebuttals aligned with each payer's own rules, including Cigna's step therapy and medical necessity requirements for anti-VEGF therapies.

FAQ: Cigna Coverage in Ohio

Q: How long does Cigna prior authorization take for Eylea/Lucentis in Ohio? A: Standard reviews take up to 5 business days. Urgent requests (when delay could jeopardize health) receive expedited review within 72 hours.

Q: What if Eylea or Lucentis is non-formulary on my Cigna plan? A: Request a formulary exception through your prescriber. Include medical necessity documentation and evidence that formulary alternatives are inappropriate or have failed.

Q: Can I request expedited appeal if my vision is worsening? A: Yes. Ohio allows expedited external reviews when standard timing would seriously jeopardize your health. Document the urgent nature with your ophthalmologist's support.

Q: Does Cigna's step therapy requirement apply if I tried bevacizumab in another state? A: Yes, documented bevacizumab trials from any location count toward step therapy requirements. Ensure you have complete treatment records to submit.

Q: What happens if the Ohio external review upholds Cigna's denial? A: The IRO decision is binding, but you retain rights to file regulatory complaints with the Ohio Department of Insurance or pursue other legal remedies.

Q: Are there patient assistance programs if Cigna won't cover these drugs? A: Yes. Regeneron offers Eylea patient assistance and Genentech provides Lucentis support programs. Income and insurance status determine eligibility.

Q: Can my retina specialist request a peer-to-peer review with Cigna? A: Yes. Many Cigna medical directors will conduct peer-to-peer discussions. Your physician can request this through provider services at 1-800-882-4462.

Q: What documentation should I keep during the appeals process? A: Maintain copies of all denial letters, appeal submissions, clinical notes, imaging reports, and correspondence with Cigna. Ohio external review requires comprehensive documentation.

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Coverage policies vary by specific Cigna plan and can change. Always verify current requirements with Cigna directly and consult with your healthcare providers about appropriate treatment options.

For additional help with Ohio health insurance appeals, contact the Ohio Department of Insurance Consumer Services at 1-800-686-1526 or visit insurance.ohio.gov.

Sources & Further Reading

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