HCPCS Level II › J codes J1097 Phenylep ketorolac opth solnPhenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml ophthalmic irrigation solution, 1 ml
Medicare coverage: Carrier judgment Status: active (October 2026 file) Medically Unlikely Edits (effective October 1, 2026) Practitioner: max 4 units per day (clinical), rationale: Prescribing Information Outpatient hospital: max 4 units per day (clinical), rationale: Prescribing Information Medicare pricing for J1097 Physician Fee Schedule (CY 2026, RVU26D) Status E: excluded from the PFS by regulation.
Payer policies and prior authorization for J1097 Payer coverage policies that name J1097 J1097 appears in 1 coverage policy from Aetna.
Payer Policy Role in policy Reviewed Document Aetna Injectable Medications (0020) listed, no stance (range J0278-J2543) Mar 5, 2026 payer document
Medicaid fee-for-service Prior authorization required or conditional in VT, WA.
AZ: $92.66 (asc), effective Oct 1, 2026 IL: $112.81 (practitioner), effective Apr 1, 2026 IN: $105.31 (professional, Advanced Practice Nurse (85%), non-facility), effective Apr 1, 2023 KY: $97.54 (asc), effective Jan 1, 2026 MS: $77.94 (comprehensive, facility), effective Oct 1, 2025 NE: $126.02 (injectables), effective Jul 1, 2026 VT: $73.65 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $118.00 (professional_administered_drugs), effective Jul 1, 2026 WY: $41.82 (outpatient_hospital_apc, Ambulatory Surgical Centers), effective Apr 1, 2026 From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.