Does Medicare Pay for Macular Degeneration Shots?

Macular degeneration is a common eye condition that can lead to blurred central vision and significant vision loss if untreated. Many individuals managing this diagnosis wonder if Medicare covers the necessary injections.

Medicare and Macular Degeneration Shots: The Basics

Macular degeneration injections involve administering specialized drugs directly into the eye to treat certain forms of the condition, such as wet age-related macular degeneration. An ophthalmologist typically performs these treatments in an office or outpatient setting.

Medicare generally covers these treatments. The primary component of Medicare responsible for covering these medical services is Medicare Part B. Part B specifically addresses medical services, including doctor visits, outpatient care, and certain medical supplies, which encompasses the administration of these specialized eye injections.

Specifics of Medicare Part B Coverage

Medicare Part B covers the costs associated with macular degeneration injections when they are considered medically necessary. This coverage includes the injectable drug itself, such as Beovu, Eylea, Lucentis, or Avastin, which are often administered in a clinical setting. Additionally, Part B covers the professional services of the physician who administers the shot, along with any associated office visits and examinations directly related to the treatment.

For coverage to apply, the treatment must be deemed medically necessary by a qualified physician. Furthermore, the procedures must be performed by a Medicare-approved provider in an appropriate healthcare setting, such as a doctor’s office or an outpatient clinic.

Medicare Part B also covers diagnostic tests, like fluorescein angiography and optical coherence tomography (OCT) scans, which are used to diagnose and monitor the progression of macular degeneration. These tests are covered when a healthcare professional considers them medically necessary for the patient’s care.

Managing Your Out-of-Pocket Costs

While Medicare Part B covers a significant portion of macular degeneration shots, beneficiaries have out-of-pocket costs. For 2025, the standard Medicare Part B annual deductible is $257. After this deductible is met, Medicare generally pays 80% of the Medicare-approved amount for covered services, leaving the beneficiary responsible for the remaining 20% coinsurance. This 20% coinsurance applies to the drug and the administration services.

Medicare Advantage Plans (Part C) are offered by private companies and cover macular degeneration shots. Their cost-sharing structures, such as copayments or coinsurance, and network requirements can differ from Original Medicare. Beneficiaries should review their specific plan details to understand their financial responsibilities.

Medicare Supplement Insurance (Medigap plans) can help cover some or all of the out-of-pocket costs associated with Original Medicare, including the Part B deductible and coinsurance. Depending on the specific Medigap plan selected, it can substantially reduce or eliminate the beneficiary’s financial responsibility for the 20% coinsurance and the Part B deductible.

The Process of Receiving Treatment

The process for receiving Medicare-covered macular degeneration shots begins with a visit to an ophthalmologist. After a thorough examination and diagnosis, the ophthalmologist determines the medical necessity of the injections. The doctor then prescribes the appropriate injectable medication and administers the treatment in their office or an approved outpatient facility.

Following the treatment, the clinic or doctor’s office is responsible for filing the claim with Medicare. They will submit the necessary documentation to ensure proper billing for the drug, the administration, and any associated services. Patients should keep records of their appointments and treatments, and they will receive an Explanation of Benefits (EOB) from Medicare detailing the services billed and the amounts covered.