Medicare beneficiaries enrolled in Advantage plans are significantly less likely to receive newer, higher-cost eye injections for serious retinal diseases, according to a large analysis of nearly 1 million patients. The study examined anti-VEGF (vascular endothelial growth factor) drugs, which are standard treatments for age-related macular degeneration and diabetic retinopathy. Researchers found that insurance plan type, not medical need, appears to influence which medication patients receive.

Why Does the Type of Medicare Plan Matter for Eye Care?

Researchers analyzed data from 930,411 Medicare beneficiaries who received a combined 12.9 million intravitreal injections (shots directly into the eye) between 2017 and 2022. They compared two groups: traditional Medicare Fee-For-Service (FFS) and Medicare Advantage (MA) plans. The findings revealed striking differences in drug selection that appear driven by cost rather than patient outcomes.

In traditional Medicare, aflibercept 2 mg was the most commonly used drug, accounting for 43.8% of injections. Bevacizumab, a lower-cost alternative, was used in 34.7% of cases. But in Medicare Advantage plans, the pattern flipped. Bevacizumab dominated at 45.1% of injections, while aflibercept dropped to 37.8%. The difference became even more pronounced for the newest drugs: faricimab and brolucizumab were used far less frequently in Advantage plans.

The most telling statistic involved repackaged bevacizumab, a generic formulation that costs substantially less than brand-name alternatives. Medicare Advantage plans used this cheaper version in 60% of cases, compared to 47% in traditional Medicare. That 13 percentage-point gap suggests insurance formularies, not ophthalmologists' clinical judgment, are steering treatment decisions.

How Do These Drug Differences Affect Patients?

All anti-VEGF drugs work by blocking abnormal blood vessel growth in the retina, a key mechanism in wet age-related macular degeneration and other sight-threatening conditions. However, they differ in potency, duration of action, and how long they remain effective between injections. Newer drugs like faricimab may offer advantages such as longer intervals between treatments, potentially reducing the burden on patients who must return to clinics every four to eight weeks.

The concern is not that bevacizumab is unsafe. It is an effective medication. The concern is that patients in Medicare Advantage plans may have fewer options when a particular drug stops working or causes side effects. If a patient's disease progresses on a lower-cost drug, switching to a newer alternative might be delayed by insurance approval processes or formulary restrictions.

• Aflibercept 2 mg: Used in 43.8% of traditional Medicare injections but only 37.8% in Medicare Advantage, a 7.7 percentage-point reduction in Advantage plans.
• Bevacizumab (generic): Dominated Medicare Advantage at 45.1% of injections, compared to 34.7% in traditional Medicare, with repackaged versions used 13 percentage points more often in Advantage plans.
• Ranibizumab: Used in 16.8% of traditional Medicare cases but only 11.9% in Medicare Advantage, a 4.9 percentage-point gap favoring the lower-cost option in Advantage plans.
• Newer drugs (faricimab and brolucizumab): Rarely used in either group but significantly less common in Medicare Advantage, suggesting cost-driven formulary restrictions limit access to the newest treatments.

Researchers noted that beneficiaries enrolled in Medicare Advantage were less likely to receive higher-cost anti-VEGF drugs, raising concerns about reduced beneficiary access to newer, more expensive anti-VEGF drugs in Medicare Advantage. This disparity matters because vision loss from retinal disease is irreversible. Once photoreceptor cells die, no medication can restore them. The goal of treatment is to stop disease progression as early as possible, and having access to the full range of options may be important for some patients.

What Should Medicare Beneficiaries Know?

If you are enrolled in a Medicare Advantage plan and have been diagnosed with age-related macular degeneration, diabetic retinopathy, or another condition requiring anti-VEGF injections, it is worth asking your ophthalmologist which drug they recommend and why. If your insurance plan restricts access to that drug, you have the right to request an exception or appeal. Many insurance companies will approve coverage for a higher-cost drug if your ophthalmologist documents that a lower-cost alternative has failed or caused adverse effects.

The study does not prove that Medicare Advantage patients receive worse outcomes, only that they receive different drugs. Long-term follow-up studies comparing vision outcomes between the two groups would be needed to determine whether these formulary differences translate into real differences in sight preservation. However, the pattern is concerning enough that patient advocacy groups and ophthalmology organizations have called for greater transparency in insurance formularies and easier access to medication switches when clinically indicated.

For now, the takeaway is clear: your insurance plan type influences which eye medications you are likely to receive, even if your ophthalmologist believes a different drug would be better for your specific condition. Understanding this reality empowers you to advocate for yourself and ensure you are not denied access to a treatment your doctor recommends without good reason.