Age-Related Macular Degeneration (MD or AMD) is a common cause of vision loss, primarily affecting older adults as it gradually damages the macula, the central part of the retina responsible for sharp, detailed central vision. This medical condition is not considered routine vision care; rather, it is a serious eye disease requiring specialized treatment. Medicare generally provides coverage for the diagnosis and treatment of macular degeneration, but the extent of that coverage depends on the specific service provided. For medically necessary care related to MD, Medicare Part B is the primary source of coverage for most beneficiaries.
How Medicare Parts Cover MD Services
Medicare Part B, which covers medical insurance and outpatient services, is the most relevant component for managing macular degeneration. This part covers physician services, diagnostic tests performed in a doctor’s office or clinic, and certain outpatient treatments for the condition. Since MD requires frequent monitoring and specialized procedures, the majority of the patient’s MD-related medical care will fall under Part B benefits.
Medicare Part D, prescription drug coverage, is primarily designed for medications that are self-administered by the patient. However, the most common and expensive treatments for Wet MD are not self-administered, meaning Part D is typically not the main payer for the disease’s active treatment. Medicare Part A, or Hospital Insurance, is rarely involved in MD care unless a patient requires an inpatient hospital stay due to a severe complication.
Coverage for Diagnostic Tests and Monitoring
Medicare Part B covers a range of advanced diagnostic tests necessary to diagnose macular degeneration and track its progression. These tests are covered when your physician determines they are medically necessary for managing the disease. A comprehensive eye exam specifically focused on the medical condition is covered, unlike routine vision screenings for eyeglasses or contacts.
Key diagnostic tools covered include Optical Coherence Tomography (OCT) scans, which provide a cross-sectional image of the retina to detect fluid and measure thickness. Fluorescein Angiography, a procedure involving a special dye to photograph blood vessels in the eye, is also covered to identify the abnormal, leaky vessels characteristic of Wet MD. These diagnostic services allow eye specialists to differentiate between the less severe Dry MD and the more rapidly progressing Wet MD.
Coverage for Active Medical Treatment
Treatment for Wet MD is heavily covered by Medicare Part B because the most effective interventions are administered by a physician in a clinical setting. The primary treatment involves anti-vascular endothelial growth factor (anti-VEGF) medications, which are injected directly into the eye to stop the growth of abnormal blood vessels and reduce fluid leakage. Common anti-VEGF drugs like Lucentis (ranibizumab), Eylea (aflibercept), and Vabysmo (faricimab), along with the off-label use of Avastin (bevacizumab), are covered under Part B as drugs administered incident to a physician’s service.
Because these drugs are administered in the doctor’s office or an outpatient facility, the drug cost and the administration fee are both billed through Part B, not the Part D prescription plan. This is an important distinction. Less frequent treatments for Wet MD, such as Photodynamic Therapy (PDT) or thermal laser procedures, are also covered by Part B when deemed medically necessary.
For the majority of people with Dry MD, there is no active medical treatment available, but high-dose nutritional supplements based on the Age-Related Eye Disease Studies (AREDS 2) formula are often recommended to slow progression. However, Medicare does not cover the cost of these AREDS 2 supplements, as they are considered over-the-counter dietary supplements and are not covered by either Part B or Part D. Patients must pay the full cost of these supplements out-of-pocket.
Understanding Out-of-Pocket Costs and Gaps
Even with comprehensive coverage under Medicare Part B, patients are responsible for a portion of the costs. The patient must first meet the annual Part B deductible before Medicare begins to pay its share. After the deductible is met, the patient typically pays a 20% coinsurance of the Medicare-approved amount for all services, including the expensive anti-VEGF drugs and the physician’s service fee.
This 20% coinsurance can quickly become substantial, especially when frequent, high-cost anti-VEGF injections are required for Wet MD treatment. Many beneficiaries choose to purchase supplemental insurance to help manage these costs. A Medigap (Medicare Supplement Insurance) plan can cover all or most of the Part B deductible and the 20% coinsurance, significantly lowering the patient’s financial responsibility. Alternatively, a Medicare Advantage (Part C) plan must cover all services covered by Original Medicare, but the out-of-pocket costs, such as copayments and deductibles, vary widely by plan. Finally, while some occupational therapy related to vision loss may be covered, most low vision aids, such as specialized magnifying devices, are generally not covered by Medicare.