Eye care · Retina · Part B drugs
In a retina practice, the drug line is the revenue line.
Anti-VEGF and geographic atrophy drugs are paid off quarterly ASP files, need JW or JZ on every single-dose line, and from April 2027 some Original Medicare patients will owe less coinsurance under the GLOBE model. Here is what changes for 2027 and the controls that protect buy-and-bill cash.
By ASP-RCM Editorial, Healthcare RCM Practice · Updated
Medicare Part B drug payment
106% of ASP by statute; biosimilars get ASP plus 6% of the reference product's ASP
First biosimilar add-on cohort ends
The 8% add-on runs 5 years from 1 Oct 2022 for biosimilars paid on ASP by 30 Sep 2022
Required on single-dose lines
JZ since 1 Jul 2023. Since 1 Oct 2023 claims without them may be returned
GLOBE coinsurance cuts begin
In selected areas covering about 25% of Original Medicare beneficiaries
What Medicare pays per billing unit, October to December 2026
CMS Part B payment limits per HCPCS billing unit. Units differ by code, so compare dose by dose, not row by row. Coinsurance is the standard 20% on every code shown.
| Code | Drug | Billing unit | Payment limit | Patient 20% | Medicare 80% |
|---|---|---|---|---|---|
| J0178 | Aflibercept (Eylea) | 1 mg | $722.25 | $144.45 | $577.80 |
| J0177 | Aflibercept HD (Eylea HD) | 1 mg | $290.90 | $58.18 | $232.72 |
| Q5147 | Aflibercept-ayyh (Pavblu) | 1 mg | $763.38 | $152.68 | $610.70 |
| J2777 | Faricimab (Vabysmo) | 0.1 mg | $31.32 | $6.26 | $25.06 |
| J9035 | Bevacizumab | 10 mg | $75.49 | $15.10 | $60.39 |
| J2781 | Pegcetacoplan (Syfovre) | 1 mg | $135.27 | $27.05 | $108.22 |
| J2782 | Avacincaptad pegol (Izervay) | 0.1 mg | $100.56 | $20.11 | $80.45 |
Source: CMS October 2026 ASP payment limit file (ASP data from Q2 2026). The split is an illustration of the 80/20 rule before deductible, sequestration and secondary payers. J2781 carries an AMP-based payment limit note. Load the January 2027 file when CMS posts it.
JW or JZ on every single-dose drug line
The rule applies to separately payable Part B drugs from single-dose containers in the office. It does not apply to multi-dose containers or to drugs packaged into an ASC or OPPS payment.
Record what was given
Document the administered amount and any discarded amount in the medical record.
Nothing discarded
Bill the administered units with JZ.
Some discarded
Bill the administered units, and report the discarded units with JW in the format your MAC requires.
Missing modifier
Since 1 Oct 2023 the claim may be returned as unprocessable until it is resubmitted correctly.
Who owes what on discarded drug
Refunds are a manufacturer bill
Under section 1847A(h), manufacturers refund CMS for discarded amounts above an applicable percentage. Your JW and JZ lines are the data CMS uses.
Low-volume doses get a higher bar
The default applicable percentage is 10%. CMS lists 90% for low-volume doses of 0.1 mL or less and 45% for 0.11 to 0.4 mL.
Your exposure is the claim
A wrong or missing modifier, or units that do not match the vial and the note, is what returns the claim or fails an audit.
The biosimilar 8% add-on: who gets it, and for how long
Under IRA section 11403 a qualifying biosimilar is paid ASP plus 8% of the reference product's ASP, instead of 6%, for 5 years.
Does not get the 8%
- A biosimilar whose ASP is above the reference product's ASP
- Any biosimilar after its 5-year window ends
- For codes paid on ASP by 30 Sep 2022: dates of service after 30 Sep 2027
- No add-on note in the CMS ASP file for that quarter
Gets the 8%
- ASP not above the reference product's ASP
- Paid on ASP by 30 Sep 2022: window from 1 Oct 2022
- First paid on ASP from 1 Oct 2022 to 31 Dec 2027: 5 years from the first day of that quarter
- CMS flags it in the ASP file notes as an 8% add-on
Two coinsurance changes that reach your patient statements
Both change what the patient owes, not what Medicare allows in total. Post from the remit, not from a flat 20% rule.
GLOBE model, from 1 April 2027
For Original Medicare patients in randomly selected areas, coinsurance on GLOBE drugs is reduced. Medicare pays the allowed amount minus that coinsurance. Medicare Advantage is not included.
Which retina drugs?
CMS's illustrative list named J0178 and J2777 as ophthalmic agents. The real list is posted quarterly, and reference products drop out once a biosimilar enters the market.
Inflation-rebate coinsurance
Drugs whose prices rise faster than inflation get coinsurance of 20% of a lower, inflation-adjusted amount. In the Oct 2026 file, every retina code shown above is at standard 20%.
Retina drug billing dates to plan around
- 1 Jul 2023
JZ required when nothing is discarded from a single-dose container.
- 1 Oct 2023
Claims missing JW or JZ may be returned as unprocessable.
- Oct 2026
Q5168 (ranibizumab biosimilar, Nufymco) appears in the CMS ASP payment file.
- 1 Jan 2027
New code Q5177, ranibizumab-hkdz biosimilar, 0.1 mg, takes effect. GLOBE model starts.
- 1 Apr 2027
GLOBE reduced coinsurance applies in selected areas, through 31 Mar 2032.
- 30 Sep 2027
8% add-on ends for biosimilars paid on ASP as of 30 Sep 2022.
Buy-and-bill cash controls for a multi-site retina group
Price file every quarter
Load each CMS ASP file on its effective date and re-price MA and commercial contracts that pay as a percent of ASP.
NDC and code match
The billed HCPCS code, NDC and units must match the vial used. A biosimilar swap needs a new code, a new NDC and often a new auth.
Auth before the vial
Check the payer's step and auth status before the drug is drawn. A denied drug line is a sunk purchase.
Inventory to claims
Reconcile vials used per site to drug units billed every week. Gaps are either missed charges or documentation errors.
Underpayment watch
Compare paid per unit to the quarter's payment limit or contract rate. Flag short-pays and post-to-ASP lag.
Score your retina drug line
Tick what is true today.
Treat the drug line as its own revenue cycle: quarterly ASP loads, JW or JZ on every single-dose line, product-level auth checks, weekly vial-to-claim reconciliation, and patient balances taken from the remit so GLOBE and inflation-rebate coinsurance post correctly.
Questions operators ask next
How does Medicare Part B pay for retina drugs in 2027?
Drugs given in the office are paid from CMS's quarterly ASP payment limit file. By statute most drugs pay 106% of ASP, and biosimilars pay their own ASP plus 6% of the reference product's ASP. Qualifying biosimilars get 8% instead of 6% for 5 years. Patients usually owe 20% coinsurance.
When does the biosimilar ASP plus 8% add-on end?
For biosimilars paid on ASP as of 30 September 2022, the 5-year window began 1 October 2022, so it ends 30 September 2027. Biosimilars first paid on ASP between 1 October 2022 and 31 December 2027 get 5 years from the first day of that quarter. A biosimilar qualifies only if its ASP is not above the reference product's.
Do I need JW or JZ on intravitreal drug claims?
Yes, for separately payable Part B drugs from single-dose containers. Use JZ when nothing is discarded and report any discarded units with JW. CMS has required JZ since 1 July 2023, and since 1 October 2023 claims without the right modifier may be returned. The rule does not apply to multi-dose containers or packaged ASC drugs.
Does the GLOBE model change what my practice is paid?
Not the total allowed amount. From 1 April 2027 to 31 March 2032, Original Medicare patients in selected areas, about 25% of beneficiaries, owe reduced coinsurance on GLOBE drugs, and Medicare pays the allowed amount minus that coinsurance. Medicare Advantage is not included. CMS publishes the drug list quarterly.
Is your drug line leaking between purchase and payment?
Send us 90 days of retina drug claims, remits and invoices. A senior Part B drug billing lead checks codes, units, JW/JZ, NDCs and payment against the current ASP file, in a free 30-minute call with a written gap report after.
Keep reading
Sources
- CMS, Medicare Part B ASP pricing files (October 2026 payment limits)
- 42 U.S.C. 1395w-3a, ASP payment methodology (LII)
- CMS, Inflation Reduction Act biosimilar temporary payment increase FAQ
- CMS, JW and JZ modifier FAQs
- CMS, Discarded drug refunds
- CMS Innovation Center, GLOBE Model and final rule
- CMS, HCPCS application summary Q3 2026, drugs and biologicals (Q5177)
- CMS, Inflation rebates in Medicare (Part B coinsurance adjustment)
Checked November 6, 2026. Payment limits change every quarter; use the file in effect on the date of service. Brand names are used only to identify codes. General information on billing operations, not legal advice.