Does Medicare Cover Macular Degeneration Treatment?

If you are one of the thousands of individuals diagnosed with Macular Degeneration then you are probably concerned about original Medicare and treatment for Macular Degeneration.  The answer to the question “does original Medicare pay for treatment of Macular Degeneration” is “yes”, but only certain treatments are covered for some individuals.  Coverage is based on the type of Macular Degeneration you have been diagnosed and the type of treatment.

What is Macular Degeneration?

Macular Degeneration (also referred to as “AMD”) is an eye disease that interferes with central visual acuity and is more common in older people. Central vision is the vision that people use to read and see objects clearly so the loss of this vision can adversely impact the ability to complete the activities of daily living. People with Macular Degeneration gradually lose their central vision.  Initially, they find it harder to see things that are directly in front of them, making it much harder to read, write, recognize faces, and drive. Macular degeneration mainly affects elderly people. It is caused by damage to the retina.

Macular degeneration is a major cause of partial-blindness among people aged 50 plus. Although the person’s central vision is affected, there is usually enough peripheral vision to allow other activities of daily life.

What are the two forms of Macular Degeneration and which one is treatable?

Macular degeneration occurs in dry and wet forms.  Dry Macular Degeneration develops gradually and there is no treatment.  Wet Macular Degeneration can develop more quickly. As soon as symptoms appear the individual requires treatment immediately. Wet Macular Degeneration is more serious than dry Macular Degeneration.

What are the symptoms of Macular Degeneration?

The symptoms can be so gradual and subtle that many people do not know they have it for quite a long time. The main symptom is blurring of the person’s central vision. Peripheral vision is not affected. The blurred central vision is still there, even when the person wears glasses.

With the diagnosis of Macular Degeneration comes the concern of payment by Medicare and treatment of Macular Degeneration

Generally, original Medicare Part A and/or Part B do not cover routine vision care except in certain cases. Original Medicare Part A (hospital insurance) does not cover vision care unless something happens to the eyes that requires hospitalization. Original Medicare Part B (medical insurance) does offer some vision benefits, but not everything related to vision care is covered. For vision care that is covered by original Medicare Part A and/or Part B, you will be responsible for paying the deductibles, copays and/or co-insurances.  The amount of these out-of-pocket costs depends on which part of original Medicare is paying for the services.  Since treatment for Macular Degeneration typically falls under original Medicare Part B (medical insurance) in the form of injections the individual will be responsible for paying their Part B deductible ($147.00 in 2013) and then 20% of the amount approved by Medicare.

What does original Medicare Part B cover with regard to vision care in general?

Medicare Part A and Medicare Part B do not cover routine vision care as part of vision benefits. However, Medicare Part B vision benefits include one preventive vision screening per year for those at high risk for glaucoma. People at high risk for this degenerative vision disease are African-Americans over 50, people with diabetes and people with a family history of glaucoma.  You must pay your deductible for any Medicare Part B services and supplies before Medicare begins to pay its share. If a doctor, health care provider or supplier does not accept assignment, the amount you pay may be higher.

With regard to Medicare and treatment for Macular Degeneration, are vision medications covered?

The Centers for Medicare and Medicaid Services (also known as “CMS”) covers a limited number of outpatient prescription drugs under original Medicare Part B.  The drugs covered under original Medicare Part B generally fall into the following categories:

  • drugs furnished incident to a physician’s service (i.e., injectable drugs such as those used to treat Macular Degeneration)
  • drugs explicitly covered by statute (i.e.,  some vaccines and oral anti-cancer drugs)
  • and drugs used in conjunction with durable medical equipment (i.e., inhalation drugs)

Most medications are covered under Medicare Part D (also known as “Prescription Drug Plans”).  Prescription Drug Plans cover the cost of some medications for Macular Degeneration, such as eye drops, but the medications must be prescribed by a licensed physician.

 In sum, Medicare and treatment for Macular Degeneration can be confusing

With regard to original Medicare and treatment for Macular Degeneration, original Medicare Part B does cover some treatment for Macular Degeneration, such as injectable drugs.  If eye drops are prescribed as part of the treatment then it must be prescribed by a licensed physician and not an optometrist and may be covered by your Prescription Drug Plan.  Original Medicare Part A and Part B offer very limited vision services in general.  However, Medicare Advantage plans sometimes offer additional vision services as part of the plan or for a small additional premium.  With regard to treatment of Macular Degeneration, if it is a service or treatment covered by original Medicare, your Medicare insurance plan must cover it as well.

What Can I do?

When shopping or comparing Medicare insurance or Prescription Drug Plans check to make sure your prescribed medications for Macular Degeneration are a part of the formulary.  A Medicare Pathways Benefit Advisor will assist you comparing not only your Medicare insurance but will also check your medications, upon request, to ensure they are covered by your Medicare Advantage and/or your Prescription Drug Plan.  You can contact a Benefit Advisor by calling 1-866-466-9118 or you can Click Here to Request a Quote and a Benefit Advisor will contact you.


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