1. No category

The coding information in this sample form is provided
for informational purposes only, is subject to change,
and should not be construed as legal advice.
Sample Health Insurance Claim Form 1500
Diagnosis Code: If the diagnosis is
exudative senile macular degeneration,
then the appropriate ICD-9-CM
diagnosis code is: 362.52.
S
3 6 2 .52
Procedure Code: Use appropriate CPT
code for intravitreal injection (67028).
Drug code: Enter unique HCPCS
J-code (J2503) for MACUGEN®
(pegaptanib sodium injection).
E
L
P
M
A
67028LT
A
1
J2503
A
1
MACUGEN® (pegaptanib sodium
injection) is available in one 0.3 mg
single-dose, pre-filled syringe.
One unit of J2503 is equal to 0.3 mg.
PLEASE PRINT OR TYPE
APPROVED OMB-0938-1197 FORM 1500 (02-12)
Please see Important Safety Information on back page and full Prescribing Information provided.
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INDICATIONS AND USAGE
MACUGEN® (pegaptanib sodium injection) is indicated for the treatment of neovascular (wet) age-related
macular degeneration.
IMPORTANT SAFETY INFORMATION
FOR OPHTHALMIC INTRAVITREAL INJECTION ONLY
MACUGEN® is contraindicated in patients with ocular or periocular infections, and in patients with known
hypersensitivity to pegaptanib sodium or any other excipient in this product.
Intravitreous injections including those with MACUGEN® have been associated with endophthalmitis. Proper
aseptic injection technique should always be utilized when administering MACUGEN®. In addition, patients
should be monitored during the week following the injection to permit early treatment, should an infection occur.
Increases in intraocular pressure have been seen within 30 minutes of injection with MACUGEN®. Therefore,
intraocular pressure as well as the perfusion of the optic nerve head should be monitored and managed
appropriately.
Rare cases of anaphylaxis/anaphylactoid reactions, including angioedema, have been reported in post-marketing
experience following the MACUGEN® intravitreal administration procedure.
Safety and effectiveness of MACUGEN® in pediatric patients have not been established.
Serious adverse events related to the injection procedure occurring in <1% of intravitreous injections included
endophthalmitis, retinal detachment, and iatrogenic traumatic cataract.
The most frequently reported adverse events in patients treated with MACUGEN® 0.3 mg for up to two years were
anterior chamber inflammation, blurred vision, cataract, conjunctival hemorrhage, corneal edema, eye discharge,
eye irritation, eye pain, hypertension, increased intraocular pressure (IOP), ocular discomfort, punctate keratitis,
reduced visual acuity, visual disturbance, vitreous floaters, and vitreous opacities. These were seen in
approximately 10% to 40% of patients.
Please see accompanying full Prescribing Information, including instructions for use.
Macugen is a trademark of Valeant Pharmaceuticals International, Inc. or its affiliates.
All other product/brand names are trademarks of their respective owners.
©2014 Valeant Pharmaceuticals North America LLC
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