Understanding Medicare Coverage and Injections for Macular Degeneration
Medicare, the healthcare programme for Americans over 65, covers a significant portion of the cost for specific injectable treatments for macular degeneration under Medicare Part B, if deemed medically necessary.
Macular degeneration is an eye disease that causes central vision blur. This condition can impact daily activities such as reading and driving.
One of the treatments covered by Medicare Part B includes VEGF inhibitor injections, such as Avastin, Eylea, Lucentis, Pegaptanib, Macugen, Aflibercept, and Verteporfin. It is worth noting that Avastin, when re-packaged, is typically preferred as the first step therapy, followed by Eylea or similar drugs. Lucentis, on the other hand, is categorized as non-preferred, which may impact coverage or require prior authorization.
When it comes to out-of-pocket costs, after Medicare pays 80% of the treatment cost, patients typically owe 20% coinsurance if the deductible is met. However, if a patient has a Medigap plan, many plans cover most or all of the 20% coinsurance, reducing out-of-pocket costs significantly.
For instance, if a treatment costs $1,000, Medicare pays $800. With most Medigap plans, the patient would owe nothing out-of-pocket. Without Medigap, the patient would pay $200 plus any deductible.
It is essential to discuss coverage with Medicare before scheduling treatment to ensure the doctor or healthcare team, specific treatment, facility, and other criteria are a match for Medicare approval.
It is also important to note that Medicare covers diagnostic eye exams related to AMD and certain treatments but not routine eye exams or elective procedures like LASIK. New therapies like red light therapy for dry AMD are emerging, but Medicare coverage for these is not established or typical.
Treatment for dry AMD generally focuses on vision aids and lifestyle, while injections primarily target wet AMD.
The cost of treatment for macular degeneration varies greatly, depending on the specific medication, amount and frequency of injections, and other factors. Costs can vary from $8,814 to $23,400 per year, or $32,491 to $70,200 after three years of treatment.
For more resources to help guide a person through the complex world of medical insurance, visit the Medicare hub. A Medicare search tool is also available to learn more about its macular degeneration coverage.
In conclusion, Medicare Part B broadly covers VEGF inhibitor injections for wet macular degeneration, with Avastin favored initially to reduce costs. Patient out-of-pocket expenses depend on deductible status and supplemental coverage, commonly around 20% coinsurance otherwise.
- Macular degeneration, a condition that causes central vision blur, is an eye disease that can affect daily activities like reading and driving.
- Certain injectable treatments for macular degeneration, like Avastin, Eylea, Lucentis, and others, are covered under Medicare Part B if deemed medically necessary.
- Avastin, when re-packaged, is typically the first step therapy, followed by Eylea or similar drugs, while Lucentis is categorized as non-preferred by Medicare.
- After Medicare pays 80% of the treatment cost, patients usually owe 20% coinsurance if the deductible is met, but this can be significantly reduced with a Medigap plan.
- If a treatment for macular degeneration costs $1,000, Medicare may pay $800, and with most Medigap plans, the patient would owe nothing out-of-pocket.
- It's crucial to discuss coverage with Medicare before scheduling treatment to ensure approval for the doctor, specific treatment, facility, and other criteria.
- Medicare does cover diagnostic eye exams related to AMD and certain treatments, but it doesn't cover routine eye exams or elective procedures like LASIK.
- New therapies for dry AMD, such as red light therapy, are emerging, but Medicare coverage for these is not always available or typical.
- The cost of treatment for macular degeneration can vary greatly, ranging from $8,814 to $23,400 per year or $32,491 to $70,200 after three years of treatment. For more information on navigating medical insurance for macular degeneration, visit the Medicare hub.
