J2789 Riboflavin epioxa/hd<=2mlRiboflavin 5'-phosphate, ophthalmic solution (epioxahd/epioxa), up to 2 ml
J2789 payment limit: $41,359.618 per UP TO 2 ML, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%. Note: Added October 2026.
25357-0024-01 Epioxa HD/Epioxa, Glaukos Corporation: 2 billing units per package (1 KIT in 1 CARTON * 1 SYRINGE, GLASS in 1 POUCH / 2 mL in 1 SYRINGE, GLASS * 1 SYRINGE, GLASS in 1 POUCH / 2 m)Status E: excluded from the PFS by regulation.
8 of 8 payer prior-auth lists that name J2789 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), HealthSpring, Humana, Molina Healthcare of Illinois, Passport by Molina Healthcare (Kentucky).
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Blue Cross Blue Shield of Arizona (AZ Blue) | AZ Blue-administered Medicare Advantage (M2K) | AZ | prior auth required | Sep 1, 2026 | AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026) | |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Standard PA code list (most commercial plans) | AZ | prior auth required | site of care: site-of-service review | Sep 1, 2026 | AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | State of Arizona employee group (SYD, S3Z) | AZ | prior auth required | site of care: site-of-service review | Sep 1, 2026 | State of Arizona Group Prior Authorization Requirements Code List (09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Teamsters group (TYW) | AZ | prior auth required | Sep 1, 2026 | Teamsters Group Prior Authorization Requirements Code List (Updated 09/01/2026) | |
| HealthSpring | Medicare Advantage | All | prior auth required | Oct 1, 2026 | 2026 Q4 Prior Authorization List | |
| Humana | Humana Healthy Horizons | OK | prior auth required | Oct 14, 2026 | Humana Healthy Horizons in Oklahoma Prior Authorization and Notification List | |
| Molina Healthcare of Illinois | Medicaid | IL | prior auth required | Jul 1, 2026 | Molina Healthcare of Illinois Codification Grid Q3 2026 | |
| Passport by Molina Healthcare (Kentucky) | Medicaid | KY | prior auth required | Jul 1, 2026 | Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026 |
J2789 appears in 5 coverage policies from Aetna, Anthem, Blue Cross Blue Shield of Massachusetts, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT).
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Corneal Remodeling (0023) | covered if criteria are met | Oct 9, 2026 | payer document |
| Aetna | Injectable Medications (0020) | listed, no stance (range J2550-J3520) | Mar 5, 2026 | payer document |
| Anthem | Corneal Collagen Cross-Linking (CG-SURG-105) | covered if criteria are met | Nov 6, 2025 | payer document |
| Blue Cross Blue Shield of Massachusetts | Corneal Collagen Cross-Linking (905) | listed, no stance | payer document | |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Corneal Collagen Cross-Linking (OTH903.028) | listed, no stance | May 1, 2026 | payer document |
Prior authorization required or conditional in MS, NE, VT, WA.
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.