Medicare Coverage for Macular Degeneration Treatment

When your doctor tells you that you have macular degeneration (AMD), it's normal to feel scared. The National Eye Institute explains that AMD affects the macula—the part of your eye that lets you see fine details straight ahead. While AMD is the leading cause of vision loss in older adults, here's some good news: it doesn't cause complete blindness, and Medicare covers treatments that can help save your sight.

There are two types of AMD. Most people have dry AMD, which happens slowly as your macula gets thinner with age. Some people develop wet AMD, where abnormal blood vessels grow and leak fluid. Wet AMD causes faster vision loss, but it's also the type that responds best to treatment. The NIH reports that anti-VEGF injections have revolutionized treatment for wet AMD and can actually improve vision, not just slow down vision loss.

What Medicare Actually Covers

Medicare Part B covers your AMD care when your doctor determines it's medically necessary. This isn't considered routine vision care—it's medical treatment for a serious eye disease.

Covered Diagnostic Tests

Medicare covers several important tests to diagnose and monitor AMD. Your doctor will use these to track your condition and decide on the best treatment. Each test gives different information about what's happening in your eye.

The tests range from simple vision checks you can do at home (like the Amsler grid) to advanced imaging like optical coherence tomography that shows detailed pictures of your retina layers. All of these tests are covered by Medicare Part B when your doctor orders them as medically necessary.

Covered Treatments

Medicare Part B covers several treatments that can help preserve your vision or even improve it. The most common treatment is anti-VEGF injections, which come in different brands at very different prices. Avastin costs about $50 per injection while Lucentis and Eylea cost around $1,500—but all three work similarly well for most patients.

Other covered treatments include photodynamic therapy (PDT), which uses a light-activated drug to treat certain types of wet AMD, laser surgery for abnormal blood vessels, and implantable telescopes for people with end-stage AMD in both eyes.

The Medicare website confirms that after you meet your Part B deductible of $257 (in 2025), you pay 20% of the Medicare-approved amount for these treatments. If you get care in a hospital outpatient setting, you'll also pay a separate facility fee.

The Truth About Drug Costs

Here's something that might shock you: the medicines that treat wet AMD all work similarly, but their prices are completely different. According to Medicare pricing data, Lucentis and Eylea cost about $1,500 to $1,600 per injection. Avastin, which many eye doctors use successfully, costs only $50 to $70 per injection. All three drugs are covered by Medicare Part B because a healthcare provider gives them to you in their office.

Why does this matter? Your 20% share for Eylea or Lucentis would be about $300 per injection. For Avastin, you'd pay about $10. Since most people need monthly injections for at least the first year, that's the difference between paying $3,600 versus $120 out of pocket. The American Academy of Ophthalmology notes that large studies have shown Avastin works just as well as the more expensive drugs for most patients.

Some doctors prefer the FDA-approved drugs (Eylea and Lucentis) while others regularly use Avastin with great success. It's worth having an honest conversation with your doctor about costs and asking whether Avastin could work for you. Your vision is important, but so is being able to afford your treatment long-term.

Medicare Advantage: Another Option

If you have a Medicare Advantage plan instead of Original Medicare, your AMD treatments are still covered. In fact, many Medicare Advantage plans offer extra benefits that Original Medicare doesn't include. These might cover routine eye exams, eyeglasses, or lower copayments for your AMD treatments.

Every Medicare Advantage plan is different, so you'll need to check your specific benefits. Some plans require you to see doctors in their network or get prior authorization before treatment. During Open Enrollment (October 15 through December 7), you can switch plans if you find one with better vision coverage.

Ways to Lower Your Costs

Nobody should skip AMD treatment because of money. If you're worried about the 20% that Medicare doesn't cover, you have options. A Medicare Supplement (Medigap) plan can help pay that 20% coinsurance. Some Medigap plans cover all of it, which means you'd pay nothing after your deductible.

The National Eye Institute also recommends AREDS2 supplements for people with intermediate AMD. These special vitamins can slow down vision loss and cost much less than medical treatments. You can buy them at most drugstores without a prescription.

Financial assistance programs can help too. Organizations like the Macular Degeneration Foundation, BrightFocus Foundation, and drug company patient assistance programs offer help with treatment costs. Your eye doctor's office usually knows about these programs and can help you apply.

What Vision Care Isn't Covered By Medicare

Medicare has clear limits on vision coverage. According to Medicare.gov, Original Medicare won't pay for:

• Routine eye exams for glasses
• Eyeglasses or contact lenses (except after cataract surgery)
• Low vision aids like magnifying devices
• Alternative treatments that aren't proven to work

This means that even though Medicare covers your AMD treatment, it won't pay for the special reading glasses or magnifying tools that might help you see better day-to-day. Some Medicare Advantage plans do cover these items, which is worth considering during Open Enrollment.

Red Flags to Watch For

Insurance companies sometimes create barriers to getting the treatment your doctor recommends. They might require "step therapy," which means trying a cheaper drug first, even if your doctor thinks a different one would work better. They might limit how often you can get injections or require multiple appeals before approving treatment.

If your insurance denies coverage for AMD treatment, you have the right to appeal the decision. Your doctor can help by writing a letter explaining why you need the specific treatment. Many denials get overturned on appeal, especially when your doctor provides good medical reasons for the treatment.

Taking Action: Your Next Steps

First, call Medicare at 1-800-MEDICARE or your insurance company to understand exactly what's covered. Ask about your deductible status, what you'll pay for injections, which drugs are covered, and whether you need prior authorization. Write down the answers and the name of the person you spoke with.

Next, talk with your eye doctor's billing staff. They deal with Medicare every day and can estimate your out-of-pocket costs, help with prior authorizations, suggest cost-saving options, and connect you with patient assistance programs. Don't be embarrassed to discuss costs—they want you to get treatment and know the system well.

Start monitoring your vision at home using an Amsler grid, which the NIH recommends for catching changes early. If straight lines start looking wavy or you notice dark spots, call your doctor immediately. Quick treatment for wet AMD can make the difference between keeping and losing your vision.

Finally, keep detailed records of everything: your treatments and dates, Explanation of Benefits statements from Medicare, any coverage denials, and notes from insurance phone calls. Good records help if you need to appeal a denial or track your medical expenses for taxes.

How a Solace Advocate Can Help

When you're facing vision loss, the last thing you should worry about is wrestling with Medicare. A Solace vision loss advocate brings deep healthcare experience to your corner. They've worked in the system as nurses, social workers, and healthcare professionals. Now they work for you, not the insurance company.

Your advocate handles the exhausting insurance battles that come with AMD treatment. When coverage gets denied, they know exactly how to appeal and what medical documentation will get it approved. They research every financial assistance program you might qualify for and help you apply. They'll even analyze whether switching from an expensive drug like Eylea to Avastin makes sense for your specific situation, potentially saving you thousands of dollars without compromising your care.

Beyond insurance, your advocate coordinates the complex logistics of AMD care. They schedule appointments with retina specialists, prepare questions to maximize your visit time, and can join appointments virtually to ensure nothing gets missed. They track your injection schedule, organize your medical records, and make sure all your doctors stay informed about your treatment plan. This coordination is crucial with AMD, where timing of treatments directly impacts whether you keep or lose your vision.

Most importantly, a Solace advocate gives you peace of mind. You have someone who truly listens, who understands both the medical and emotional challenges of vision loss, and who never stops fighting for your care. You don't have to navigate this alone.

Frequently Asked Questions about Medicare Coverage for Macular Degeneration Treatments

Does Medicare cover the new AMD drugs like Vabysmo and Syfovre?

Yes, Medicare Part B covers FDA-approved AMD treatments given in your doctor's office, including newer drugs. You'll pay the same 20% coinsurance after meeting your deductible. However, newer drugs often cost more than older options, so ask about your expected out-of-pocket costs.

Can I get Avastin if my doctor usually prescribes Eylea?

You have the right to discuss all treatment options with your doctor. While some doctors prefer FDA-approved eye drugs, many successfully use Avastin for AMD. If cost is a concern, ask your doctor directly whether Avastin would work for your condition. Most doctors want you to get treatment you can afford.

Will Medicare cover both eyes if I need injections in each?

Yes, Medicare covers medically necessary treatment for both eyes. You'll pay your 20% coinsurance for each injection. If you need both eyes treated on the same day, you'll pay for both treatments, though some doctors' offices offer slight discounts for bilateral treatment.

What if I can't afford the 20% that Medicare doesn't cover?

You have several options: get a Medigap plan to cover the 20%, apply for patient assistance programs through drug companies or foundations, ask your doctor about switching to less expensive Avastin, look into Medicare Savings Programs if you have limited income, or work with your doctor's office on a payment plan.

How often will I need eye injections for wet AMD?

Treatment schedules vary, but most people start with monthly injections for the first three months. After that, your doctor will check your response and might extend the time between shots. Some people eventually need injections every 2-3 months, while others need them more or less often. Medicare covers the schedule your doctor determines is medically necessary.