New Enhanced OMIDRIAssure® Patient Access Programs

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Passage of the Consolidated Appropriations Act 2023 has secured separate payment status in ASCs for OMIDRIA through January 1, 2028.

HOPD separate payment status is secured for OMIDRIA starting January 2025 through January 1, 2028.*

OMIDRIA now has separate payment status in ASC's through January 1, 2028

OMIDRIA has a unique billing code: J1097
Phenylephrine 10.16 mg/mL and ketorolac 2.88 mg/mL ophthalmic irrigation solution, 1 mL.1

OMIDRIA is reimbursed per mL; therefore, providers should always use 1 mL as the billing unit and bill for 4 units when OMIDRIA is utilized.

*Section 4135(b) CAA provides for both a transitional period (December 29, 2022, to December 31, 2024) and a specified period (January 1, 2025, to January 1, 2028) during which nonopioid pain management drugs such as OMIDRIA will qualify for separate payment in the ASC setting.

ASCs use this unique permanent HCPCS code to bill CMS and other payers for separate payment. HOPDs use this unique HCPCS code to bill commercial payers and Med Advantage.

ASC=ambulatory surgical center; HCPCS=Healthcare Common Procedure Coding System; HOPD=hospital outpatient department.

Learn about OMIDRIAssure®: support at every step

The OMIDRIAssure® program offers patients options to assist with the cost of OMIDRIA:

We Pay the Difference patient reimbursement program for commercially insured patients

Equal Access patient assistance program for government-insured, underinsured, or uninsured patients (based on financial need and eligibility requirements)

Dedicated access to comprehensive reimbursement programs for your cataract procedures:

Field Reimbursement Managers to help you navigate through the reimbursement pathway

OMIDRIA is on the VA National Formulary with no PA required.

Contact Us about access and reimbursement.

Based on your Medicare or commercial plan selection, your coverage may require a copay for OMIDRIA.

PA=prior authorization; VA=United States Department of Veterans Affairs.

REFERENCE: 1. Centers for Medicare & Medicaid Services. HCPCS January 2024 Index. Accessed February 15th, 2024.