Does Medicare Cover Eye Injections for Macular Degeneration?

Does Medicare Cover Eye Injections for Macular Degeneration?

Medicare’s vision coverage is famously lacking, but Part B will help cover medically necessary treatment for macular degeneration. Here’s how to qualify.

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As we get older, our eyesight often begins to weaken, which can cause issues in day-to-day life. While most people think of cataracts or glaucoma when it comes to losing sight as we age, many forget about macular degeneration.

Age-related macular degeneration affects around 11 million people in the United States, with numbers expected to grow, and is the leading cause of vision loss in people over the age of 50. In this piece, we discuss what age-related macular degeneration is and how Medicare covers treatment options and diagnosis.

What is macular degeneration?

Simply put, age-related macular degeneration (or AMD), is an eye disease that causes a loss of vision. There are two types of AMD: dry macular degeneration and wet macular degeneration. Dry AMD typically is a slow deterioration of the center of the retina, which can take place over years. Wet AMD is when leaky blood vessels grow under the retina. It is less common but happens much faster and can cause a complete loss of central vision.

Age-related macular degeneration should not be confused with diabetic retinopathy, which is damage to the blood vessels at the back of the eye caused by diabetes complications, though the two may share symptoms.

Macular degeneration does not show very many symptoms in the early stages, so it is not uncommon for people to be completely unaware they have it. As the disease progresses, you may begin to show symptoms such as:

  • A blind spot or dark area in the center of your vision
  • Blurry or fuzzy vision
  • Difficulty recognizing faces
  • Loss of central vision
  • Straight lines become wavy

Unfortunately, there is no cure for AMD. But when it is detected early, you may be able to slow the progression of the disease through medication. Most macular degeneration treatment options to help manage AMD are injected into the bloodstream or directly into the eye.

How does Medicare cover eye injections for macular degeneration?

It is important to note that Original Medicare (Medicare Part A and Medicare Part B) does not cover regular eye exams. However, Medicare does cover diagnostic tests and treatment if you have age-related macular degeneration.

For Medicare to cover the exam or treatment option, it must be deemed medically necessary. Though the injection is a medication, it is actually covered under Part B instead of a Medicare Part D prescription drug plan. The injection is usually an outpatient procedure and administered by a trained healthcare professional.

Medicare pays 80% of the approved cost, with your copay being the remaining 20%. You must also meet the Part B deductible. If you have Medicare supplement insurance, also known as a Medigap plan, it may cover much or all of your out-of-pocket costs. Common medications administered for AMD include:

  • Aflibercept
  • Avastin
  • Eylea
  • Lucentis
  • Verteporfin

Your doctor will prescribe the treatment they consider most effective and necessary for you.

Does Medicare Advantage cover injections for macular degeneration?

Medicare Advantage plans, also known as Medicare Part C, are legally required to have the same level of coverage as Original Medicare. The majority of Advantage plans also include additional benefits, one of the most common being vision coverage, so even routine eye exams can be covered.

Part C plans are sold through private insurers, so cost and coverage options vary based on who you purchase from. The level of coverage for the injections may be greater than Original Medicare, and your coinsurance may also be different.

You can compare Medicare plans quickly and easily by entering your zip code into our Find a Plan tool. You’ll see the plans available in your area as well as any extra benefits they offer and what you can expect to pay for premiums, deductibles, and more.

Can you prevent macular degeneration?

Before discussing how you may prevent age-related macular degeneration, it is important to consider risk factors for the disease. Risk factors include:

  • Age: This is the biggest risk factor in AMD, with risk being highest after 55.
  • Genetics: If you have a close family member that has or had AMD, you are more likely to get it.
  • Smoking: If you smoke cigarettes or vape nicotine you are significantly more likely to get AMD than a non-smoker.
  • Weight: Being obese increases the likelihood of having AMD.

While you can't control your age or genetics, you can quit smoking and it is never too late to start taking your physical health seriously. Be sure to go over your risk factors with your doctor.

Now that we know what puts us at risk, how are we supposed to try and prevent age-related macular degeneration? There are a few preventative steps you can take, such as:

  • Decrease sun exposure: Wear hats and sunglasses helps protect your eyes from the sun, as sun exposure can increase risk of AMD.
  • Diet: A diet with plenty of fruit and dark green leafy vegetables provides vitamins C and E, Beta-Carotene, and zinc which have been shown to reduce the risk of AMD.
  • Know your family medical history: This keeps you aware of your personal level of risk and can make you more vigilant of the warning signs.
  • Maintain a healthy weight: Keeping up with your exercise and following a good diet helps prevent obesity, which reduces the risk of severe AMD.
  • Quit smoking and vaping: This is great for your health in general, but also helps reduce the risk of macular degeneration.
  • Regular eye exams: Get your eyes checked regularly and make sure your doctor does a test of the macula to help detect any possible warning signs.

Staying healthy and keeping doctor visits consistent is an all-around great way to reduce your risk of age-related diseases.

Additional resources

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