Eye injections can cost thousands at list price, but most patients pay far less — or nothing. Here’s how Medicare, insurance, and assistance programs cover your medication.
One of the most common questions patients ask after a diagnosis of wet macular degeneration, geographic atrophy, diabetic macular edema, or retinal vein occlusion is: what is this going to cost me? It’s a fair question. The medications used to treat these conditions — anti-VEGF agents like Eylea HD, Vabysmo, and Eylea/Pavblu, and the newer complement inhibitors Syfovre and Izervay — carry list prices that can reach thousands of dollars per injection. For patients facing monthly or bimonthly treatment indefinitely, that arithmetic is alarming. The reality for most patients is far more manageable than those list prices suggest, and the team at Retina Care works hard to make sure cost is never the reason a patient skips treatment they need.
How Medicare Covers Eye Injections
Intravitreal injections are covered under Medicare Part B, not Part D. This distinction matters because Part B covers physician-administered drugs — medications given in a clinical setting by a healthcare provider — while Part D covers drugs you pick up at a pharmacy. Anti-VEGF injections and complement inhibitors for geographic atrophy all qualify as Part B drugs, which gives them strong Medicare coverage.
Under standard Medicare Part B, after you meet the annual deductible (about $250), Medicare pays 80 percent of the Medicare-approved amount for the drug and the injection procedure. You are responsible for the remaining 20 percent. For a drug with a Medicare-approved payment of $2,000, that 20 percent is $400 per injection — still significant for patients on fixed incomes who need injections every four to eight weeks, often in both eyes.
A quick note here: doctors are required to purchase these medications from pharmacutical companies. We pay for them and have them available to administer to patients as needed. When our office charges you or your insurance $2,000 for your injection, its because we have already paid that to by the drug. Its a reimbursement
Medigap (Medicare Supplement Insurance)
Most patients with traditional Medicare also carry Medigap supplemental insurance, also called Medicare Supplement Insurance. Depending on your Medigap plan, it typically pays the 20 percent that Medicare leaves behind. Patients with robust Medigap coverage — Plan G or Plan F — often pay nothing for their intravitreal injections beyond the annual deductible. If you’re not sure what your Medigap plan covers, our billing team can walk you through exactly what to expect before your first injection.
Medicare Advantage Plans
Medicare Advantage (Part C) plans cover Part B drugs but may have different cost-sharing structures. Some plans have copays or coinsurance rates that differ from traditional Medicare. Coverage for newer medications like Vabysmo, Syfovre, and Izervay sometimes requires prior authorization under Medicare Advantage plans. Retina Care’s team manages prior authorization requests routinely and pursues appeals when necessary to ensure patients receive the treatment recommended by Dr. Peter Karth.
Why Avastin Is Often the Starting Point
Bevacizumab (Avastin) is an off-label anti-VEGF medication that has been used in retina practice for nearly two decades. It is compounded into an intravitreal formulation at approximately $50 to $70 per dose — a fraction of the cost of FDA-approved alternatives. Multiple large clinical trials, including the CATT study in the United States and the IVAN study in the United Kingdom, demonstrated that bevacizumab produces visual outcomes reasonably close to ranibizumab (Lucentis) in patients with wet AMD. Many insurance plans, including some Medicare Advantage plans, require bevacizumab as a first-line treatment before approving more expensive agents.
For those whose disease doesn’t respond adequately, or for patients with geographic atrophy, diabetic macular edema, or retinal vein occlusion where a different agent may be clinically preferable, Dr. Peter Karth’s team will initiate the insurance process to move to the appropriate medication.
Medication-Specific Coverage and Costs
Eylea (aflibercept) and Eylea HD
Eylea and its high-dose formulation Eylea HD are FDA-approved anti-VEGF agents with strong Medicare coverage under Part B. Prior authorization may be required for Medicare Advantage patients and commercial insured patients, particularly for Eylea HD. For patients with adequate Medigap coverage, out-of-pocket cost is typically very low or zero. Regeneron and other programs offer patient assistance programs.
PavBlu (aflibercept biosimilar)
PavBlu is an FDA-approved biosimilar to Eylea (aflibercept) with equivalent clinical outcomes. It is covered under Medicare Part B and offers a cost-effective option for patients. The manufacturer offers assistance programs.
Vabysmo (faricimab)
Vabysmo is covered under Medicare Part B.. Prior authorization is commonly required. Genentech offers a patient assistance program for eligible patients who face cost barriers.
Syfovre and Izervay (geographic atrophy)
Both Syfovre and Izervay are covered under Medicare Part B for documented geographic atrophy. Prior authorization typically requires imaging confirmation of GA. Apellis (Syfovre) and Astellias (Izervay) each have patient assistance programs for eligible patients. Out-of-pocket costs for patients with Medigap coverage are generally every low or even zero, and our team identifies assistance programs proactively for patients without supplemental coverage.
Manufacturer Patient Assistance Programs
Every major manufacturer of intravitreal medications operates a patient assistance program for patients who meet income or coverage criteria. These programs are not automatic — they require applications, documentation, and follow-up — but they can eliminate out-of-pocket costs entirely for eligible patients in some situations. Retina Care’s team assists patients with these applications as a routine part of care. We have helped thousands of patients throughout Eugene, Roseburg, Salem, the Willamette and Umpqua Valley, and the Oregon coast access medications at no cost through these programs.
Commercial Insurance
For patients under 65 with commercial insurance, coverage for intravitreal injections varies by plan. Most major commercial insurers cover FDA-approved anti-VEGF agents and, increasingly, the complement inhibitors for geographic atrophy. Step therapy requirements — which require trying a less expensive drug first — are common. Retina Care manages the prior authorization and step therapy processes for patients with commercial insurance and challenges denials when the clinical case supports a specific medication. Fortunately, patient assistance programs are especially generous with commercial plans. Most patience have very low or zero medication costs in these commercial plans.
Our Commitment to Access
Dr. Peter Karth and the team at Retina Care approach the cost question directly: no patient should lose vision because they couldn’t afford treatment. We work proactively with every patient’s insurance coverage before treatment begins, identify assistance programs when costs remain, and advocate with insurers when coverage is denied. For the overwhelming majority of patients in Oregon — those on Medicare with Medigap, those on Medicare Advantage, and those with commercial insurance — out-of-pocket costs for intravitreal injections can be brought to very low or zero with proper navigation.
If you have a question about what your specific coverage means for your treatment, call our office. Our billing team will review your insurance and give you a clear picture of what to expect.
At Retina Care, retinal specialist Peter Karth, MD, MBA, FASRS, FACS is happy to help you with your retina concerns. Please call 541-873-8462 to schedule an appointment at a location near you.