Does Medicare Cover Macular Degeneration?
- Macular degeneration is a leading cause of vision loss in older adults. Find out whether Medicare covers some costs for treating age-related macular degeneration.
Medicare covers the costs of treating some eye health conditions. Treatments for macular degeneration are usually covered by Medicare, but the coverage and costs depend on the type of plan you have, your doctor and the treatment.
Original Medicare (Part A and Part B) covers some macular degeneration treatments if your doctor determines they're medically necessary. Original Medicare doesn't typically cover routine vision exams, eyeglass or contacts, however.
Medicare Advantage (Medicare Part C) plans are sold by private insurance companies as an alternative way to get your Original Medicare benefits. All Medicare Advantage plans cover macular degeneration the same way Original Medicare does, and many plans may offer additional vision care benefits that Original Medicare doesn't pay for. These types of benefits aren't available with all plans, so it's important to compare the Medicare Advantage plans available in your specific ZIP code.
What Is Macular Degeneration?
Macular degeneration is a degenerative condition where the macula becomes damaged. The macula is the central part of the retina; damage to it can lead to a loss of central vision. Age-related macular degeneration (AMD) is a common condition that typically first affects individuals in their 50s and 60s.
There are two types of AMD:
- Dry AMD: Dry AMD is the most common and accounts for around 80% of AMD cases. It is the less serious form and occurs when parts of the macula get thinner with age, leading to clumps of protein being formed. Central vision is gradually lost and there is no way to treat dry AMD.
- Wet AMD: Wet AMD is less common but a much more serious form of AMD. It occurs when new, abnormal blood vessels start to grow beneath the retina. They may leak blood or other fluids, which can lead to scarring of the macula. The degeneration of vision occurs much faster than it does with dry AMD.
Does Medicare Cover Macular Degeneration Treatments?
Medicare Part B may cover some diagnostic tests and treatment for AMD.
Medicare covers the cost of the screening appointment only if your physician deems it to be medically necessary to diagnose and treat the disease. When the treatment is outpatient, the care falls under Part B of Medicare. In this case, most of the treatment options, which include eye drops and injectables, fall under this category.
After meeting the annual Part B deductible, you will be required to pay 20% of the cost of diagnosis or treatment.
If you have a Medicare Advantage plan that offers vision benefits, the costs may vary.
Which Treatments Are Covered by Medicare?
Part B Medicare covers some AMD treatments, including:
- Lucentis: An option FDA-approved for treating wet AMD
- Eylea: An antivascular endothelial growth factor treatment that works by inhibiting VEGF in wet AMD
- Avastin: A cancer drug that is not FDA-approved for treating AMD but has been found to be useful
- Verteporfin (Visudyne): A type of ocular photodynamic therapy for patients with new blood vessels growing under the retina
- Implantable Miniature Telescope (IMT): A treatment used for patients who have central blindness in both eyes that cannot be corrected through glasses, medication or surgery.
- Aflibercept: A recombinant protein treatment for wet AMD
How Much Does Medicare Pay for Eylea Injections?
Eylea is a brand name for aflibercept. The Injections are used for treating wet AMD. If your doctor agrees that Eylea injections are an appropriate treatment option, they may be covered under part B of Medicare and you will only be required to pay 20% once you meet your annual deductible.
Does Medicare Pay for Lucentis Injections?
Lucentis is a brand name for ranibizumab. Similar to Eylea, it may be covered under Part B of Medicare and you will only have to pay for 20% of the cost.
What Does Medicare Pay for Vision Care?
Original Medicare doesn't cover standard eye exams for glasses or contact lenses. However, Medicare does cover certain eye treatments and procedures if you have a chronic eye condition. Medicare covers:
- Surgery to repair the function of the eye lost to chronic conditions (e.g. cataracts)
- An eye exam to diagnose potential vision problems if you're having vision problems that may point to a serious condition
Medicare only covers routine eye tests under the following circumstances:
- You have diabetes
- You are at high risk for glaucoma
As mentioned above, many Medicare Advantage plans offer additional benefits such as vision care, glasses and contacts. Benefits and availability can vary greatly though, so be sure to get help comparing your specific local options.