HCPCS Level II › Q codes Q5168 Inj. nufymco, 0.1 mgInjection, ranibizumab-leyk (nufymco), biosimilar, 0.1 mg
Medicare coverage: Carrier judgment Status: active (October 2026 file) Medicare pricing for Q5168 Medicare Part B drug payment limit (ASP, October 2026) Q5168 payment limit: $26.384 per 0.1 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%. Note: Added October 2026.
NDCs that bill under Q5168 (CMS ASP NDC-HCPCS crosswalk, October 2026) 70710-2173-01 Nufymco, Zydus Pharmaceuticals (USA) Inc.: 5 billing units per package (1 VIAL, GLASS in 1 CARTON / .05 mL in 1 VIAL, GLASS)Physician Fee Schedule (CY 2026, RVU26D) Status E: excluded from the PFS by regulation.
Payer policies and prior authorization for Q5168 29 of 29 payer prior-auth lists that name Q5168 require prior authorization or set conditions: Aetna, Blue Cross Blue Shield of Arizona (AZ Blue), Blue Shield of California Promise Health Plan, CarePlus Health Plans, Cigna, 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) 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) Blue Shield of California Promise Health Plan Promise Health Plan Medi-Cal CA prior auth required Sep 1, 2026 Medi-Cal Prior Authorization List Aetna Medicare Advantage All prior auth required Aug 25, 2026 Aetna Medicare Part B drug list (partbname.xml) Aetna Medicare Advantage All prior auth required May 1, 2026 Participating provider precertification list for Aetna® Aetna Commercial All prior auth required May 1, 2026 Participating provider precertification list for Aetna® Cigna ACA/IFP All prior auth required Jul 1, 2026 Master Precertification List (For Health Care Providers) Cigna Basic Standard All prior auth required Jul 1, 2026 Master Precertification List (For Health Care Providers) Cigna Complete/PHS+/Preferred All prior auth required Jul 1, 2026 Master Precertification List (For Health Care Providers) HealthSpring Medicare Advantage All prior auth required Aug 1, 2026 2026 Q4 Prior Authorization List CarePlus Health Plans CarePlus Health Plans FL prior auth required Step therapy Jan 1, 2027 Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List We have updated our CarePlus Health Plans Prior Authorization and Notification List for CarePlus Medi Humana Humana D-SNP (FL) FL prior auth required New PA requirement; Step therapy Jul 1, 2026 H1036-280 Humana Fully Integrated Florida prior authorization and notification list Humana Humana D-SNP (IL) IL prior auth required Step therapy Jan 1, 2027 Humana Dual Fully Integrated Illinois prior authorization and notification list Humana Humana D-SNP (IN) IN prior auth required Step therapy Jan 1, 2027 Humana PathWays Dual Care (HMO-POS D-SNP) prior authorization and notification list Important notes: Humana Humana D-SNP (MI) MI prior auth required New PA requirement; Step therapy Oct 14, 2026 Humana Dual Integrated (health maintenance organization Dual Eligible Special Needs Plan (HMO D- SNP) Michigan prior authorization and notification list (PAL) Humana Humana D-SNP (SC) SC prior auth required New PA requirement; Step therapy Jul 1, 2026 Humana Dual Integrated South Carolina prior authorization and notification list Humana Humana D-SNP (VA) VA prior auth required New PA requirement; Step therapy Jul 1, 2026 Prior authorization and notification list Humana Dual Fully Integrated H2875-001 (Virginia) Humana Dual Fully Integrated H2875-003 (Virginia) Humana Humana Healthy Horizons KY prior auth required Oct 7, 2026 Humana Healthy Horizons in Kentucky Prior Authorization and Notification List Humana Humana Healthy Horizons LA prior auth required Oct 14, 2026 Humana Healthy Horizons in Louisiana Prior Authorization and Notification List Humana Humana Healthy Horizons OH prior auth required Oct 14, 2026 Humana Healthy Horizons in Ohio prior authorization and notification List Humana Humana Healthy Horizons OK prior auth required Oct 14, 2026 Humana Healthy Horizons in Oklahoma Prior Authorization and Notification List Humana Humana Healthy Horizons SC prior auth required Oct 14, 2026 Humana Healthy Horizons in South Carolina prior authorization and notification list Humana Humana Healthy Horizons VA prior auth required Oct 14, 2026 Humana Healthy Horizons in Virginia professionally administered medication prior authorization and notification list Humana Humana MA and D-SNP All prior auth required Step therapy Jan 1, 2027 Medicare Advantage and Dual Eligible Special Needs Plans prior authorization and notification list Important notes: 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
Payer coverage policies that name Q5168 Q5168 appears in 7 coverage policies from Aetna, Centene, Premera Blue Cross, UnitedHealthcare, Wellmark Blue Cross Blue Shield.
Payer Policy Role in policy Reviewed Document Aetna Dexamethasone Ophthalmic Implant (Ozurdex) and Insert (Dextenza) (0795) listed, no stance Oct 5, 2026 payer document Aetna Revakinagene Taroretcel-lwey (Encelto) (1079) listed, no stance Oct 5, 2026 payer document Aetna Vascular Endothelial Growth Factor Inhibitors for Ocular Indications (0701) covered if criteria are met Oct 5, 2026 payer document Centene Ranibizumab (Byooviz, Cimerli, Lucentis, Nufymco, Ranluspec, Susvimo) (CP.PHAR.186) covered if criteria are met Feb 1, 2026 payer document Premera Blue Cross (effective January 1, 2027) Vascular Endothelial Growth Factor (VEGF) Receptor Inhibitors for Ocular Disorders (5.01.620)Page | 7 of 20 | ∞ listed, no stance Sep 8, 2026 payer document UnitedHealthcare Ophthalmologic Vascular Endothelial Growth Factor (VEGF) Inhibitors (2026D0042AQ) listed, no stance Jul 1, 2026 payer document Wellmark Blue Cross Blue Shield Vascular Endothelial Growth Factor (VEGF) Inhibitors for Ophthalmic Use (09.03.12) listed, no stance Oct 1, 2025 payer document
Recent prior-auth changes Oct 14, 2026: PA removed, Humana Sep 1, 2026: PA added, Blue Shield of California Promise Health Plan Aug 1, 2026: PA removed, Blue Shield of California Promise Health Plan Aug 1, 2026: PA added, HealthSpring Jul 1, 2026: PA added, CarePlus Health Plans Jul 1, 2026: PA added, Humana Jul 1, 2026: PA added, Passport by Molina Healthcare (Kentucky) Jul 1, 2026: PA added, Blue Shield of California Promise Health Plan Jul 1, 2026: PA added, Molina Healthcare of Illinois May 1, 2026: PA added, Aetna Medicaid fee-for-service AZ: $269.33 (outpatient_hospital), effective Jul 1, 2026 IL: $257.74 (practitioner), effective Jul 1, 2026 KS: $19.79 (default, Exempt Physician), effective Oct 1, 2026 NE: $287.64 (injectables), effective Jul 1, 2026 OK: $269.60 (physician, non-facility), effective Jul 1, 2026 VT: $0.00 (outpatient_hospital_opps), effective Jul 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.