In this episode of Evidence Based Retina, Rishi Singh, MD, sits down with Thomas Stone, MD, to discuss the financial barriers limiting patient access to branded anti-VEGF therapies and the strategies retina specialists can employ to address them. Dr. Stone is a retina specialist in practice at Retina Associates of Kentucky.
Branded anti-VEGF access fast facts:
- Copay costs for branded anti-VEGF treatments are insurmountable for some patients, even when the branded drug is the most effective treatment.
- Three insurance profiles are typically seen in retina practice according to Dr. Stone:
- Traditional Medicare patients with a secondary plan generally face no prior authorization requirements and have full drug coverage.
- Commercial insurance patients may require step therapy but typically have access to copay cards.
- Medicare Advantage patients face a copay of roughly $300 to $500 per injection, per eye, because their plans cover approximately 80% of drug costs.1,2
- Charitable foundation funding that previously offset Medicare Advantage copays was largely unavailable for most of 2025, though some funding has begun to return.
- Practice strategies for improving access include bevacizumab as a fallback option, pharmaceutical patient access programs, insurance counseling, carrier advocacy, and patient enrollment in charitable foundations.
Barriers to accessing anti-VEGF therapy
Dr. Stone notes that effective branded anti-VEGF agents exist for macular degeneration, diabetic eye disease, and retinal vein occlusion, but some patients are not able to afford the significant copay for each injection. He explains that the core problem is a carrier landscape that does not consistently support the treatments clinicians believe their patients need.
“The burden is basically insurmountable for most patients.”
The situation has worsened in recent years. Until approximately a year and a half ago, one foundational fund covered many patients' copays, providing a reliable pathway to care that many practices used. Unfortunately, that fund is no longer reliably available.3 In its absence, practices have leaned on sampling and other stopgaps, but these are not long-term solutions.
Insurance categories
Dr. Stone organizes the access problem into three patient categories, each with a different insurance profile and level of access to branded therapy.
Traditional Medicare
Traditional Medicare patients with a secondary plan generally do not require prior authorization and have full drug coverage. Access is not a significant problem for this group.4
Commercial insurance
Commercial insurance patients may require step therapy but typically have copay cards available, making branded therapy accessible in most cases.
Medicare Advantage
Medicare Advantage patients are the primary group experiencing an access gap. These plans cover approximately 80% of branded anti-VEGF drug costs, but because the drugs can cost thousands of dollars per injection, the remaining 20% amounts to roughly $300 to $500 per injection, per eye.1,2
Foundation funding had offset this cost in the past, but it has declined significantly over the past year, though some funding is beginning to return intermittently.
Strategies to address the gap in care
Dr. Stone emphasized that some patients who had been doing well on a branded agent and can no longer afford it may not do as well on alternatives.3 Reverting to bevacizumab is typically the first fallback, and sampling can cover isolated cases, but neither is a long-term solution for patients who need repeated treatment.
Patient access programs
Another option is a pharmaceutical charity care or patient access program, available through most drug manufacturers. Under these programs, the drug is provided at no cost to the patient, and the practice provides the injection without charging for the drug.
These programs can require a dedicated staff member to manage the logistics, and drug delivery is not always timely. For patients who need branded therapy and have no other means of access, however, this can be a viable path.
Counseling patients on insurance selection
For Medicare Advantage patients, the drug coverage structure can make branded anti-VEGF therapy copays too costly to maintain. Dr. Stone's practice has built a multi-part approach to changing that over time. The first component is pre-enrollment counseling. When patients can afford it, the recommendation is traditional Medicare with a secondary plan.
Medicare Advantage companies actively incentivize agents to recruit patients turning 65, offering free dental or vision benefits that make these plans attractive without making the implications for drug access clear. Once a patient is enrolled in Medicare Advantage, leaving it requires underwriting, which makes it very difficult to return to traditional Medicare.
The American Society of Retina Specialists has provided guidance to members on the issue, and pharmaceutical companies have produced informational materials, but patient awareness remains limited.4 Dr. Stone's practice now pairs the counseling conversation with a referral to an insurance broker specializing in Medigap and secondary coverage, giving patients a concrete next step.
Engaging carriers
Dr. Singh has found that engaging carriers, such as by writing directly to Medicare Advantage medical directors, can make an impact and recommends that clinicians make the case in writing for why these drugs matter for their patients. Dr. Stone adds that clinical vignettes are particularly effective for this kind of communication.
Monitoring charitable foundations for patient enrollment windows
The most impactful strategy Dr. Stone describes is active foundation monitoring combined with a pre-consented patient list.
Good Days, formerly the primary copay support source, has had little funding available in 2025. Other foundations have become intermittently active, however. These include HealthWell, the Assistance Fund, and the Copay Relief Fund. All three allow practices to register online and receive email alerts when funds open.
Enrollment windows are short, however. A fund that opens Monday morning may close Tuesday afternoon. When a fund opens, the practices that benefit most are the ones already prepared. Dr. Stone mobilizes all available staff to work through a list of pre-consented patients who were registered in the foundation system at their initial visit, enabling immediate enrollment when a window opens.
“You want to get everybody on the phone like a fire drill and get as many of your patients enrolled in these foundations.”
Key takeaways
- Branded anti-VEGF therapy is effectively out of reach for some patients, such as those who have Medicare Advantage, due to the significant copay. This cost can be roughly $300 to $500 per injection for branded anti-VEGF therapy.
- Dr. Stone identified practice-level strategies for improving access when foundation funding is unavailable:
- Reverting to bevacizumab
- Utilizing pharmaceutical patient access programs that can provide branded drugs at no cost to the patient, but require dedicated staff resources
- Counseling patients on insurance selection before enrollment to select traditional Medicare with a secondary plan if they can afford it
- Communicating with insurance carriers to advocate for improved drug coverage
- Enrolling patients in charitable foundations to cover copay costs
- Dr. Stone recommends that practices maintain a pre-consented patient list to enable immediate enrollment when charitable foundation funds become available, as windows are brief
This article was written by Sonia Kelley, OD, MS, based on the recorded video from Drs. Singh and Stone.
