Does Medicare Cover Avastin Eye Injections for Macular Degeneration?
Seeking treatment for macular degeneration could raise important questions about Medicare’s role in the cost of care. You might wonder if Medicare covers Avastin eye injections. The answer is yes, under qualifying conditions.
This article aims to demystify the circumstances under which Medicare could provide coverage, discuss potential out-of-pocket expenses, and highlight what steps to take to receive these possible 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, possibly aiding in the management of macular degeneration.
- Medicare Part B might provide coverage for Avastin eye injections for macular degeneration, with patients generally responsible for about 20% of the Medicare-approved cost after meeting the annual deductible.
- Avastin could be 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.
Compare Plans in One Step!
Enter Zip Code
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 may be attributed to age-related changes or genetic predisposition within families. Macular degeneration tests could help identify the presence of this condition.
For its treatment, one of the prevalent therapeutic approaches may be the administration of injectable drugs, such as Avastin, either into the bloodstream or directly into the eye. This method may be chosen over certain treatments, including photodynamic therapy and alternative treatments.
What is Avastin?
Avastin, also referred to as bevacizumab, is a pharmaceutical agent that was initially formulated to treat 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 potential factor in restraining the growth of abnormal blood vessels in the eye, which could improve patients’ vision.
Vascular endothelial growth factor (VEGF) might also play 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 could 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 potential cost implications of treating macular degeneration could be vital. Medicare, a national health insurance program in the United States, will likely provide coverage for Avastin eye injections for macular degeneration under specific conditions.
Some of these conditions may 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, will likely be included under Medicare Part B.
Medicare Part B and Avastin Injections
Medicare Part B might cover Avastin eye injections if they have been 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, patients might have to bear at least 20% of the Medicare-approved cost for Avastin eye injections.
Apart from Avastin, Medicare Part B may also provide macular degeneration treatment, encompassing essential diagnostic tests, injections, medications, and surgical procedures.
Medicare Advantage Plans and Avastin Coverage
Some Medicare Advantage Plans, often known as Part C, could act as an alternative to original Medicare, offering the same Part A (hospital insurance) and Part B (medical insurance) coverage, but may also offer prescription drug coverage and sometimes add other benefits not provided by original Medicare.
The criteria for Avastin coverage under certain Medicare Advantage plans will likely be determined by the member-specific benefit plan document and applicable laws. The coverage for Avastin may differ among various Medicare Advantage plans, with beneficiaries generally responsible for paying up to 20% of the cost through Medicare Part B coverage.
The possible factors that may influence the coverage of Avastin under Medicare Advantage plans might include cost, local coverage area policies, and insurer coverage policies.
Comparing Avastin with Other Macular Degeneration Treatments
Avastin is just one of the several treatment options available for macular degeneration. While it is effective, it may also be important to compare it with other treatments for macular degeneration like Lucentis and Eylea.
Studies have shown that Avastin may be comparable in effectiveness to Lucentis for treating macular degeneration, while Eylea might be more effective than Avastin in reducing the need for ongoing therapy in patients with neovascular age-related macular degeneration.
Avastin vs. Lucentis
Avastin and Lucentis, both developed by Genentech, may be comparable in terms of their effectiveness in treating macular degeneration. However, a major point of difference between these two treatments might be their treatment cost. Avastin could be a more cost-effective option for many patients.
However, while both Avastin and Lucentis may 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 could be advantageous in the treatment of macular degeneration.
Potential Out-of-Pocket Costs and Financial Assistance for Avastin Eye Injections
While some of the Medicare and Medicare Advantage Plans may offer substantial help in covering the potential 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 might bear up to 20% of the Medicare-approved cost for Avastin eye injections.
However, several patient assistance programs may be 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, could be additional insurance policies that individuals may purchase from private companies to assist in covering their portion of expenses in Original Medicare.
Some of these plans may have the potential to provide Medicare coverage for the expenses that could be associated with Avastin injections under Medicare Part B, particularly the 20% coinsurance that Medicare might not cover, provided that the individual is a qualified beneficiary.
Patient Assistance Programs
Patient Assistance Programs (PAPs) are programs that will likely be established by pharmaceutical and medical supply manufacturers to help patients who cannot afford their medications and supplies.
Some of these programs could offer financial assistance to patients to help them afford their medications.
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 may be crucial when contemplating the use of Avastin for macular degeneration treatment. The doctor could provide a detailed explanation of how Avastin works, its potential side effects, and how it may compare with other treatment options.
Before discussing Avastin treatment, it may be 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 may also be 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 should make the most out of their appointment. Before discussing Avastin treatment with your doctor, it may be important to obtain informed consent and:
- Research the potential 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, you might want to consider examining and cleaning your eye, ensuring its disinfection and numbness, checking eye pressure, and following instructions for administering anesthetic and povidone-iodine drops.
It may also be 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 could be 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, might include:
- Do I have wet or dry macular degeneration?
- 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?
Apart from Avastin, you may also want to 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 will likely be 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)
Summary
Avastin could play a crucial role in treating macular degeneration, a condition that affects millions of people worldwide. While certain Medicare and Medicare Advantage plans might 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 could be significantly reduced, possibly 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 might cover the cost of Avastin injections if they are administered by a doctor or healthcare professional in their office.
→ Does Medicare pay for Vabysmo injections?
No, Medicare might not cover Vabysmo injections for patients who may be 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 has also been effective in treating macular degeneration by helping to prevent the growth of abnormal blood vessels in the eye.
→ How does Avastin compare to other treatments for macular degeneration like Lucentis and Eylea?
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.
ZRN Health & Financial Services, LLC, a Texas limited liability company
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.