Does Medicare Cover Avastin Eye Injections for Macular Degeneration?

Seeking treatment for macular degeneration raises important questions about Medicare’s role in the cost of care. Specifically, does medicare cover avastin eye injections? The answer is yes, under qualifying conditions.

This article aims to demystify the circumstances under which Medicare provides coverage, discuss potential out-of-pocket expenses, and highlight what steps to take to receive these benefits.

 

Key Takeaways

  • Avastin (bevacizumab) is an injectable drug initially designed for cancer treatment, effective in curbing the growth of abnormal blood vessels in the eye, thereby aiding in the management of macular degeneration.

 

  • Medicare Part B provides coverage for Avastin eye injections for macular degeneration, with patients generally responsible for 20% of the Medicare-approved cost after meeting the annual deductible.

 

  • Avastin is a cost-effective treatment option for macular degeneration compared to other drugs like Lucentis and Eylea, though the latter may reduce the need for ongoing therapy.

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Avastin Eye Injections and Macular Degeneration

Macular degeneration is an ocular condition that results in the blurring of an individual’s central vision. The condition can be attributed to age-related changes or genetic predisposition within families. Macular degeneration tests can help identify the presence of this condition.

For its treatment, one of the prevalent therapeutic approaches is the administration of injectable drugs, such as Avastin, either into the bloodstream or directly into the eye. This method is often chosen over certain treatments, including photodynamic therapy and alternative treatments.

 

Avastin Eye Injections and Macular Degeneration

What is Avastin?

Avastin, also referred to as bevacizumab, is a pharmaceutical agent that was initially formulated for the purpose of treating cancer. It was initially utilized in the treatment of a range of cancers, such as:

 

  • metastatic colorectal cancer
  • breast cancer
  • non-small cell lung cancer
  • glioblastoma
  • renal cell carcinoma
  • ovarian cancer

 

However, a study conducted by the National Institutes of Health (NIH) revealed that Avastin demonstrated comparable effectiveness to Lucentis in treating age-related macular degeneration and maintaining visual acuity.

 

How Avastin Treats Macular Degeneration

Avastin manages macular degeneration by curbing the vascular endothelial growth factor (VEGF), a key factor in restraining the growth of abnormal blood vessels in the eye, thereby improving patients’ vision.

Vascular endothelial growth factor (VEGF) plays a pivotal role in the pathogenesis of wet age-related macular degeneration (AMD) by stimulating angiogenesis, resulting in heightened vascular permeability and proliferation of atypical blood vessels.

By using Avastin, the growth of these abnormal blood vessels can be slowed down, thereby reducing the advancement of macular degeneration and frequently resulting in vision improvement for patients. However, potential side effects of Avastin treatment may encompass:

 

  • Eye redness
  • Temporary blurry vision
  • Pain
  • Elevated intraocular pressure
  • High blood pressure
  • Headache
  • In more severe instances, infection or cardiovascular events.

Medicare’s Coverage of Avastin Eye Injections

Comprehending the cost implications of treating macular degeneration is vital. Medicare, a national health insurance program in the United States, does provide coverage for Avastin eye injections for macular degeneration under specific conditions.

 

Does medicare cover macular degeneration injections

 

 

These conditions often include the treatment being deemed reasonable and necessary for conditions such as wet age-related macular degeneration (wet AMD).

The coverage for these injections, which Medicare covers, is included under Medicare Part B.

 

Medicare Part B and Avastin Injections

Medicare Part B covers Avastin eye injections if they are identified as reasonable and necessary for treating conditions such as wet age-related macular degeneration (wet AMD). Following the fulfillment of the annual deductible for Medicare Part B, which amounts to $240 in 2024, patients generally bear 20% of the Medicare-approved cost for Avastin eye injections.

Apart from Avastin, Medicare Part B provides medicare cover macular degeneration treatment, encompassing essential diagnostic tests, injections, medications, and surgical procedures.

 

Medicare Advantage Plans and Avastin Coverage

Medicare Advantage Plans, often known as Part C, are an alternative to original Medicare, offering the same Part A (hospital insurance) and Part B (medical insurance) coverage, but can also offer prescription drug coverage and may add other benefits not provided by original Medicare.

The criteria for Avastin coverage under Medicare Advantage plans are determined by the member specific benefit plan document and applicable laws. The coverage for Avastin can differ among various Medicare Advantage plans, with beneficiaries generally responsible for paying 0% to 20% of the cost through Medicare Part B coverage.

The factors that may influence the coverage of Avastin under Medicare Advantage plans include cost, local coverage area policies, and insurer coverage policies. The typical expense for Avastin eye injections within Medicare Advantage plans ranges from $50 to $60 per dose.

Comparing Avastin with Other Macular Degeneration Treatments

Avastin is just one of the several treatment options available for macular degeneration. While it has been shown to be effective, it is also important to compare it with other treatments for macular degeneration like Lucentis and Eylea.

 

Is macular degeneration covered by medical insurance

 

 

Studies have shown that Avastin is comparable in effectiveness to Lucentis for treating macular degeneration, while Eylea has been found to be more effective than Avastin in reducing the need for ongoing therapy in patients with neovascular age-related macular degeneration.

Furthermore, Avastin is priced at approximately $40 per injection, whereas Lucentis carries a cost of about $2,000 per injection, showcasing a significant difference in their average sales price.

 

Avastin vs. Lucentis

Avastin and Lucentis, both developed by Genentech, are comparable in terms of their effectiveness in treating macular degeneration. However, a major point of difference between these two treatments is their treatment cost. The average cost of Avastin is around $50 per dose, whereas Lucentis is priced at approximately $2,000 per dose, making Avastin a more cost-effective option for many patients.

However, while both Avastin and Lucentis display similar mild side effects, Lucentis may have more severe side effects, such as intraocular infections, cataracts, and retinal detachment.

 

Avastin vs. Eylea

Eylea, one of the macular degeneration drugs, is a relatively newer drug compared to Avastin and has also been used to treat macular degeneration. Like Avastin, Eylea works by inhibiting VEGF, thus slowing down the progression of the disease. However, one advantage that Eylea has over Avastin is that it may require fewer injections, thereby potentially reducing the treatment burden on the patients.

Both Avastin and Eylea function by impeding the growth of blood vessels, which is advantageous in the treatment of macular degeneration.

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Out-of-Pocket Costs and Financial Assistance for Avastin Eye Injections

While Medicare and Medicare Advantage Plans offer substantial help in covering the costs of Avastin injections, patients may still be left with out-of-pocket expenses. As mentioned before, following the fulfillment of the annual deductible for Medicare Part B, patients generally bear 20% of the Medicare-approved cost for Avastin eye injections. The typical out-of-pocket expense for Avastin eye injections is around $50 per dose.

However, several patient assistance programs are available for Avastin eye injections, including:

 

  • Avastin Access Solutions
  • Genentech Access Solutions
  • Genentech Patient Foundation
  • AmeriPharma Specialty
  • Programs from the American Society of Retina Specialists

 

Medicare Supplement Plans

Medicare Supplement plans, also referred to as Medigap, are additional insurance policies that individuals can purchase from private companies in order to assist in covering their portion of expenses in Original Medicare.

These plans have the potential to provide medicare cover for the expenses associated with Avastin injections under Medicare Part B, particularly the 20% coinsurance that Medicare does not cover, provided that the individual is a qualified beneficiary.

 

Patient Assistance Programs

Patient Assistance Programs (PAPs) are programs established by pharmaceutical and medical supply manufacturers to help patients who cannot afford their medications and supplies.

 

Does medicare cover wet macular degeneration

 

 

These programs offer financial assistance to patients to help them afford their medications. For Avastin, eligibility criteria for these programs are applicable, and it is not applicable to patients utilizing federal or state government programs to cover their Genentech medicine.

Patients can anticipate receiving financial assistance of up to $25,000 per calendar year from Avastin patient assistance programs. To apply for these programs, patients can contact Avastin Access Solutions at (888) 249-4918 to receive a referral to independent co-pay assistance foundations, or utilize the financial assistance tool offered by Avastin to determine which programs may best suit their needs.

Tips for Discussing Avastin Eye Injections with Your Doctor

A comprehensive discussion with your doctor is crucial when contemplating the use of Avastin for macular degeneration treatment. The doctor can provide a detailed explanation of how Avastin works, its side effects, and how it compares with other treatment options.

 

Does medicaid cover macular degeneration

 

Prior to discussing Avastin treatment, it is advisable to conduct thorough research on the medication, make a note of any pertinent questions, compile a list of current medications and medical history, consider being accompanied by a support person, and contact your doctor’s office to inquire about any pre-appointment instructions.

It is also advisable to:

 

  • Address the expenses related to Avastin eye injections
  • Evaluate your insurance coverage
  • Consider potential out-of-pocket costs
  • Explore any available financial aid options.

 

Preparing for the Appointment

A well-prepared patient can make the most out of their appointment. Prior to discussing Avastin treatment with your doctor, it is important to obtain informed consent and:

 

  • Research the risks and benefits of the treatment
  • Understand its applications in treating various conditions
  • Be aware of potential side effects
  • Consider the associated cost

 

To prepare for your appointment, consider examining and cleaning your eye, ensuring its disinfection and numbness, checking eye pressure, setting aside one and a half to two hours, and following instructions for administering anesthetic and povidone-iodine drops.

It is also crucial to notify your doctor about any recent surgeries, history of blood clots, instances of coughing up blood, heart failure, and the presence of high blood pressure.

 

Understanding Your Doctor’s Recommendations

Grasping your doctor’s advice is key to making an informed decision about your treatment. Several inquiries you may pose to your physician concerning macular degeneration injections, such as Avastin eye injections for macular degeneration, include:

 

  • Do I have wet macular degeneration or dry?
  • Do I have it in one eye or both eyes?
  • What stage of the disease do I have?
  • How often should I come in for injections?

 

While Avastin is a secure medication, the complete understanding of the benefits and risks of Avastin for eye conditions is still under exploration. Apart from Avastin, you may also discuss about the efficacy of other VEGF inhibitor medications such as ranibizumab and pegaptanib, and the results and effectiveness of treatments like Lucentis and Eylea with your doctor.

There are different types of Medicare Advantage plans.

These are the most common plans offered by several different insurance companies.

  • Health Maintenance Organization Plans (HMO)
  • Preferred Provider Organization Plans (PPO)
  • Private Fee-for-Service Plans (PFFS)
  • Special Needs Plans (SNPs)

 

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Summary

In conclusion, Avastin plays a crucial role in treating macular degeneration, a condition that affects millions of people worldwide. While Medicare and Medicare Advantage plans cover a significant portion of the costs associated with Avastin injections, patients may still have out-of-pocket expenses.

However, with the availability of Medicare Supplement plans and Patient Assistance Programs, these costs can be significantly reduced, making Avastin a viable and cost-effective treatment option for many.

Frequently Asked Questions

 

 

Does Medicare pay for Avastin injections?

Yes, Medicare Part B plans can cover the cost of Avastin injections if they are administered by a doctor or healthcare professional in their office.

 

How much does Avastin eye injections cost?

The cost of Avastin eye injections is approximately $182.06 per injection, according to the Centers for Medicare & Medicaid Services reimbursement rates for dose and injection procedures cited by a JAMA Ophthalmology study (2022). Retail price for one dose is around $55, but the actual cost may be lower if covered by insurance.

 

Does Medicare pay for Vabysmo injections?

No, Medicare does not cover Vabysmo injections for patients using government programs to pay for their medication and administration services. It is important to be aware of potential co-pays for drug and administration costs under these programs.

 

What is Avastin used for?

Avastin, also known as bevacizumab, is primarily used to treat cancer, but it is also effective in treating macular degeneration by helping to prevent the growth of abnormal blood vessels in the eye. This is its main purpose.

 

→  How does Avastin compare to other treatments for macular degeneration like Lucentis and Eylea?

In conclusion, Avastin has been proven to be as effective as Lucentis and Eylea for treating macular degeneration and may be a more cost-effective option for many patients.

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 ZRN Health & Financial Services, LLC, a Texas limited liability company

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Speak with a licensed insurance agent

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Russell Noga
( Medicare Expert )

Russell Noga is the CEO of ZRN Health & Financial Services, and head content editor of several Medicare insurance online publications. He has over 15 years of experience as a licensed Medicare insurance broker helping Medicare beneficiaries learn about Medicare, Medicare Advantage Plans, Medigap insurance, and Medicare Part D prescription drug plans.