Newsroom · Sioux Falls
Does Medicare Cover Eye Injections for Macular Degeneration? Sioux Falls, 2026
Medicare pays 80% of the shot. The other 20% is the part nobody explains before the first appointment.
The bottom line
- Yes, Part B covers the injections for wet macular degeneration. CMS says Part B may cover certain diagnostic tests and treatments, including treatment with certain injectable drugs, and that you pay 20% of the Medicare-approved amount after the deductible.
- The drugs are expensive. CMS's own 2024 Part B spending data puts the average approved amount per claim at $1,918.34 for Eylea, $2,419.05 for Vabysmo and $3,141.51 for Eylea HD.
- That makes your 20% roughly $383.67 to $628.30 per injection — every four to eight weeks, for as long as the treatment continues.
- Original Medicare alone has no annual ceiling on that 20%. A Medigap policy or a Medicare Advantage maximum out-of-pocket are the two ways to cap it.
- In South Dakota, CDC's modeled estimates put any age-related macular degeneration at 20.91% of adults 65 to 84 and 50.84% of adults 85 and older, with the vision-threatening stage — the kind that gets injected — at 1.49% and 12.61% of those groups.
Yes. Medicare Part B covers anti-VEGF eye injections for wet age-related macular degeneration, and after you meet the annual Part B deductible, you pay 20% of the Medicare-approved amount for the drug and the doctor's services, per CMS. The coverage question is the easy one. The question that actually keeps people up is the second one: 20% of what, how often, and does it ever stop? For the drugs most commonly used, CMS's own spending data says 20% lands somewhere between about $177.83 and $628.30 per injection — and under Original Medicare by itself, there's no annual maximum that ever shuts the meter off.
This guide works through the whole thing in plain numbers: what the drugs actually cost in Medicare's own published data, what a year of treatment looks like out of your pocket, how a Medigap policy or a Medicare Advantage plan changes the math, and how common this diagnosis really is in South Dakota. Every figure comes from CMS, CDC or NIH data read this week, or from plan documents we opened ourselves. Nothing is from memory or a search summary.
The short answer
Part B covers the tests and the treatment. CMS's coverage page for macular degeneration says Part B "may cover certain diagnostic tests and treatments (including treatment with certain injectable drugs)," and that "after you meet the Part B deductible, you pay 20% of the Medicare-approved amount for the drug and your doctor's services." It adds one line that costs people real money when they miss it: "In a hospital outpatient setting, you also pay a separate facility copayment."
Source: CMS — Macular degeneration tests & treatment coverage.
For plan year 2026, that deductible is $283 for the year, per CMS's own premiums and deductibles fact sheet issued November 14, 2025. The 20% coinsurance that follows it is the number this whole guide is about, because it's a percentage of a drug price, not a flat copay — and anti-VEGF drugs are among the most expensive things Part B pays for.
Source: CMS — 2026 Medicare Parts A & B Premiums and Deductibles (Fact Sheet, Nov. 14, 2025), plan year 2026.
The terms, defined once
Anti-VEGF: a class of drug injected into the eye to slow abnormal blood-vessel growth. Part B: the medical half of Original Medicare, which covers drugs a clinician administers to you. Part D: the drug benefit for prescriptions you fill at a pharmacy. Coinsurance: a percentage of the approved cost that you pay, as opposed to a fixed dollar copay. Deductible: what you pay first each year before coinsurance starts. MOOP: maximum out-of-pocket, the annual ceiling a Medicare Advantage plan must set. Formulary: a plan's list of covered drugs, grouped into tiers that set your share — a Part D concept that does not govern these injections. Prior authorization: a plan's requirement that it approve the treatment before you get it.
What's actually happening in your eye
Age-related macular degeneration damages the macula, the small central part of the retina that handles sharp, straight-ahead vision. The National Eye Institute describes it as very common, affecting about 11 million people in the United States, and a leading cause of vision loss for older adults. People age 55 and older are more likely to have it.
Source: National Eye Institute (NIH) — Age-Related Macular Degeneration (AMD).
There are two forms, and the difference decides whether injections ever enter the conversation. Dry AMD is the common one: the macula thins with age, through early, intermediate and late stages. NIH is blunt that there's no treatment for late dry AMD. Wet AMD — the advanced neovascular form — is less common and usually causes faster vision loss, as abnormal blood vessels grow at the back of the eye and leak. That's the form anti-VEGF injections treat, and NIH lists those injections and photodynamic therapy as the treatments that may be able to stop further vision loss.
Source: National Eye Institute (NIH) — Age-Related Macular Degeneration (AMD).
So the first fork in the road is diagnostic, not financial. Most people with macular degeneration never get an injection, because they have the dry form. The people who do get injections are usually on a schedule measured in weeks, not a one-time procedure — and that's exactly why the cost per injection matters so much more than it would for a single surgery.
Just got the diagnosis and wondering what your plan does with it?
You can work through this on your own with the numbers below. If you'd rather have someone local read your plan documents with you, that's what we're here for. No pressure, no cost to talk.
Book a conversation →Why the shot is a Part B drug, not a Part D drug
This trips up almost everyone, including people who have had Medicare for a decade. A drug you pick up at the pharmacy in Brandon or Tea runs through Part D, your drug plan, with a formulary and tiers and — since 2025 — a hard annual cap on what you spend out of pocket. A drug a clinician injects into your eye at the clinic runs through Part B instead, as a medical service.
That one distinction has a large consequence. The Part D out-of-pocket cap, $2,100 for 2026 and rising to $2,400 for 2027 under CMS's published parameters, never touches these injections. They aren't Part D drugs. There's no tier to appeal to a lower level, no pharmacy to shop, and no cap in the Part B rules at all. Your protection, if you have any, comes from a Medigap policy or from a Medicare Advantage plan's own annual ceiling — not from the drug benefit.
Part D out-of-pocket figures: CMS — CY2027 Medicare Advantage and Part D Rate Announcement (April 6, 2026), Part D benefit parameters, plan years 2026 and 2027. Part B coinsurance and the absence of an annual Part B ceiling: CMS — Medicare costs at a glance.
What one injection costs, in CMS's own numbers
CMS publishes an annual file of what Medicare Part B actually spent, drug by drug, with the average amount per claim and per beneficiary. The most recent one covers data year 2024 and was released in June 2026. Here are the five anti-VEGF drugs used in the eye, straight out of that file, with the 20% coinsurance column calculated from CMS's own averages at Medicare's standard 20% rate.
| Drug | Billing code | Avg. approved per claim | Your 20% | Avg. per beneficiary, year | Medicare beneficiaries, 2024 |
|---|---|---|---|---|---|
| Eylea HD (Aflibercept 8 mg) | J0177 | $3,141.51 | $628.30 | $9,971.70 | 66,767 |
| Vabysmo (Faricimab) | J2777 | $2,419.05 | $483.81 | $11,119.52 | 172,503 |
| Beovu (Brolucizumab) | J0179 | $2,125.16 | $425.03 | $8,747.09 | 1,552 |
| Eylea (Aflibercept) | J0178 | $1,918.34 | $383.67 | $8,065.22 | 293,280 |
| Lucentis (Ranibizumab) | J2778 | $889.13 | $177.83 | $3,820.85 | 33,741 |
Source: CMS — Medicare Part B Spending by Drug (data year 2024, released June 2026), read directly from CMS's published data endpoint this week. Dollar figures are national averages across all Part B settings in data year 2024, not a price quote for any clinic. The 20% column is Medicare's standard Part B coinsurance rate applied to CMS's published average.
Read the beneficiary column for a second. Nearly 293,280 people on Medicare had an Eylea claim in 2024, across 1,233,027 claims. That's roughly four injections per person for the year, on average. Vabysmo reached 172,503 people across 792,936 claims. These aren't rare treatments: they're a routine, recurring, expensive part of ordinary eye care after 70.
Your 20% Part B coinsurance per injection, calculated from CMS's published average Medicare-approved amount per claim, data year 2024. Source: CMS — Medicare Part B Spending by Drug (data year 2024, released June 2026).
$383.67
Your 20% on an average Eylea injection (CMS data year 2024)
$628.30
Your 20% on an average Eylea HD injection (CMS data year 2024)
$283
Annual Part B deductible, plan year 2026 (CMS)
No cap
Annual limit on Part B coinsurance under Original Medicare alone
Sources: CMS — Medicare Part B Spending by Drug (data year 2024, released June 2026); CMS — 2026 Medicare Parts A & B Premiums and Deductibles (Fact Sheet, Nov. 14, 2025); CMS — Medicare costs at a glance.
A year of injections, worked out in dollars
One injection is an expense. A schedule is a budget problem. Treatment intervals vary by person and by drug — some people are injected every four weeks, others stretch to eight or twelve — so take the example below as arithmetic, not a prediction about your own eye.
Say your retina specialist treats you with Eylea 8 times over a calendar year, and each claim lands at CMS's published 2024 average of $1,918.34. Under Original Medicare, with no supplement, in plan year 2026:
| Line | Amount | Where it comes from |
|---|---|---|
| 8 injections at $1,918.34 approved | $15,346.72 | CMS average approved per claim, data year 2024 |
| Annual Part B deductible, paid first | $283 | CMS, plan year 2026 |
| 20% coinsurance on the remaining $15,063.72 | $3,012.74 | Medicare's standard Part B coinsurance rate |
| Your share for the year | $3,295.74 | Deductible plus coinsurance, before any facility copay |
Our arithmetic, applied to CMS's own published figures. Sources: CMS — Medicare Part B Spending by Drug (data year 2024, released June 2026) and CMS — 2026 Medicare Parts A & B Premiums and Deductibles (Fact Sheet, Nov. 14, 2025). Your own approved amounts will differ by drug, dose and setting.
About $3,295.74, then, for a fairly ordinary year — and that's before the hospital outpatient facility copay CMS mentions, before the office visits and imaging that come with the injections, and before anything else Part B pays for that year. Twelve injections instead of eight pushes the same math past $4,900. Two eyes being treated at once doubles the drug line.
Where you get the shot changes the bill
CMS spells out the setting difference in one sentence: in a hospital outpatient setting, you also pay a separate facility copayment. The injection is identical. The drug is identical. The bill is not, because a hospital outpatient department bills a facility fee that a freestanding clinic doesn't.
Source: CMS — Macular degeneration tests & treatment coverage.
In the Sioux Falls market, where both large health systems — Sanford Health and Avera Health — run outpatient departments alongside clinic-based specialty care, this is a practical question with a real dollar answer, not a theoretical one. It's fair to ask the scheduler which setting your injections will be billed from, and whether a clinic-based option exists. Sometimes it doesn't, for good clinical reasons. Sometimes nobody ever asked.
What Medigap does to this math
Medigap, also called Medicare Supplement, is a private policy that pays some of what Original Medicare leaves to you. The plans are standardized by letter under federal rules, so a Plan G from one insurer covers the same benefits as a Plan G from another — the price and the service differ, not the benefit chart.
For eye injections, one row of that chart does nearly all the work: Part B coinsurance. Plans A, B, D, G, M and N cover it in full. Plans K and L cover 50% and 75% of it respectively, with their own annual out-of-pocket maximums. Here's how the standardized plans handle the pieces of a Part B injection bill.
| Medigap plan | Part B coinsurance (the 20%) | Part B deductible | What you'd pay in the example above |
|---|---|---|---|
| Plan G | Covered in full | Not covered | $283 |
| Plan N | Covered, with copays up to $20 for some office visits | Not covered | $283 plus any visit copays |
| Plan D | Covered in full | Not covered | $283 |
| Plan L | 75% covered | Not covered | 25% of the coinsurance, up to the plan's annual out-of-pocket maximum |
| Plan K | 50% covered | Not covered | 50% of the coinsurance, up to the plan's annual out-of-pocket maximum |
| No supplement | You pay all of it | You pay it | $3,295.74, with no annual ceiling |
Benefit rows follow CMS's standardized Medigap benefit chart. Source: CMS — Choosing a Medigap Policy (Publication 02110). Dollar column is our arithmetic on the worked example above. Plans C and F are not available to people first eligible for Medicare on or after January 1, 2020.
That's the clearest argument anyone will ever make to you for a Medigap policy, and it's worth being honest about the other side: you pay a monthly premium for that protection every month of every year, including the years when nothing happens to your eyes. For someone already on injections, the arithmetic is usually easy. For someone who isn't, it's a genuine judgment call about risk, not an obvious answer.
Timing matters more than most people realize
Your Medigap open enrollment window — the one period when an insurer can't turn you down or charge you more for your health history — runs for six months starting when you're 65 or older and enrolled in Part B. Outside it, South Dakota insurers can medically underwrite the application. A new wet AMD diagnosis after that window has closed can change what you're able to buy. That's not a reason to panic; it's a reason to ask the question early rather than after the third injection.
Not sure whether your current coverage caps this?
Most people can find the answer in their own plan documents in about ten minutes. If you'd rather not, we'll pull it up with you and read it out loud. Free, local, no obligation.
Ask us to check →What Medicare Advantage does to this math
A Medicare Advantage plan replaces Original Medicare's billing with the plan's own. It must cover what Original Medicare covers, so the injections are covered, but three things change at once: the cost-sharing is the plan's, the provider has to be in the plan's network, and the plan can require prior authorization before the treatment happens.
The good news is the ceiling. Every Medicare Advantage plan must set a maximum out-of-pocket. Per KFF's analysis of CMS plan data published May 28, 2026, for 2026 no plan may set its in-network maximum above $9,250 or its combined in- and out-of-network maximum above $13,900, and the enrollment-weighted national averages are $5,421 in network and $9,825 combined.
Source: KFF — Medicare Advantage Out-of-Pocket Limits: Variation and Trends (May 28, 2026), plan year 2026.
Locally, the three Sioux Falls plans whose 2026 documents we opened directly sit well below those national figures: Align ChoicePlus (PPO) at a $4,900 combined maximum, Align ChoiceElite (PPO) at $3,500 combined, and Wellmark's Blue Medicare Advantage Enhanced (PPO) at $4,200 in network and $5,000 combined. For someone facing an open-ended injection schedule, a number like that is the difference between a bad year and an unbounded one.
Sources: Sanford Health Plan — 2026 Align ChoicePlus (PPO) Summary of Benefits; Sanford Health Plan — 2026 Align ChoiceElite (PPO) Summary of Benefits; Wellmark Advantage Health Plan — 2026 Blue Medicare Advantage Enhanced PPO Annual Notice of Change. Plan year 2026.
The trade-off is the paperwork and the network. KFF's review of insurer-reported data found Medicare Advantage insurers made nearly 53 million prior authorization determinations in 2024 — about 1.7 requests per enrollee — and denied 4.1 million of them, 7.7%, in full or in part. Only 11.5% of denials were appealed, and of the ones that were, 80.7% were partially or fully overturned. That last pair of numbers is the practical lesson: denials get reversed far more often than they get challenged.
Source: KFF — Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024 (Jan. 28, 2026), data year 2024, published January 28, 2026.
The 2026 Minnehaha County plan landscape
For context on what's actually sold here: CMS's plan year 2026 landscape data for Minnehaha County shows 15 plans that carry drug coverage — 5 standard Medicare Advantage PPOs open to anyone with Medicare, 4 Dual-Eligible Special Needs Plans for people who also have Medicaid, 2 Institutional Special Needs Plans for nursing-home residents, and 4 Medicare Cost plans, which work differently again. Here's the whole roster rather than a summary number.
| Plan | Carrier | Type | Monthly premium | CMS stars | Stability |
|---|---|---|---|---|---|
| Aetna Medicare Signature (PPO) | Aetna / CVS | PPO | $0 | 3.5★ | Average (3.5★) |
| Align ChoicePlus (PPO) | Sanford Health | PPO | $0 | 3.5★ | Average (3.5★) |
| Aetna Medicare Enhanced Extra (PPO) | Aetna / CVS | PPO | $52 | 3.5★ | Average (3.5★) |
| Align ChoiceElite (PPO) | Sanford Health | PPO | $66 | 3.5★ | Average (3.5★) |
| Blue Medicare Advantage Enhanced (PPO) | Wellmark / BCBS | PPO | $80 | 3.5★ | Average (3.5★) |
| UHC Dual Complete SD-Q1 (PPO D-SNP) | UnitedHealthcare | D-SNP | $41.50 | 4.5★ | Strong (4★+) |
| UHC Dual Complete SD-S2 (PPO D-SNP) | UnitedHealthcare | D-SNP | $41.50 | 4.5★ | Strong (4★+) |
| Aetna Medicare Dual (PPO D-SNP) | Aetna / CVS | D-SNP | $41.50 | 3.5★ | Average (3.5★) |
| Aetna Medicare Full Dual (PPO D-SNP) | Aetna / CVS | D-SNP | $41.50 | 3.5★ | Average (3.5★) |
| Great Plains Medicare Advantage (HMO I-SNP) | Sanford Health | I-SNP | $12 | Not yet rated | Unrated (too new) |
| Great Plains Medicare Advantage Gold (HMO I-SNP) | Sanford Health | I-SNP | $72 | Not yet rated | Unrated (too new) |
| Medica Prime Solution Thrift w/Rx (Cost) | Medica | Cost | $92.80 | 3.5★ | Average (3.5★) |
| Medica Prime Solution Standard w/Rx (Cost) | Medica | Cost | $58.70 | 3.5★ | Average (3.5★) |
| Medica Prime Solution Core w/Rx (Cost) | Medica | Cost | $221.70 | 3.5★ | Average (3.5★) |
| Medica Prime Solution Premier w/Rx (Cost) | Medica | Cost | $334.70 | 3.5★ | Average (3.5★) |
Source: CMS Medicare Advantage / Part D Landscape and CMS Star Ratings, plan year 2026, as maintained in this site's own county data file. Star ratings are CMS's published overall rating; "not yet rated" means the contract is too new for CMS to score. 39,532 people in Minnehaha County have Medicare, per CMS county enrollment data for 2026. We do not offer every plan listed here.
A plan's premium tells you nothing about how it treats a $2,419.05 injection. Two plans with the same $0 premium can handle Part B drugs completely differently, and the answer lives in the Summary of Benefits under Part B drugs or chemotherapy drugs, not on the front page of the mailer.
Eylea, Vabysmo, Avastin: the money side of the drug choice
Which drug goes in your eye is your retina specialist's call, made on clinical grounds. It's worth knowing that the choice also moves your bill by hundreds of dollars per visit, because the conversation about alternatives is easier to have if you know that.
Avastin, generically bevacizumab, is a cancer drug that ophthalmologists have used off-label in the eye for close to two decades, at a small fraction of the cost of the drugs designed for it. NIH funded a head-to-head trial precisely because of that cost gap: the Comparison of AMD Treatments Trials, covering 1,185 patients at 43 clinical centers in the United States, reported that Avastin is as effective as Lucentis for treating AMD. NIH also notes plainly that the FDA has not licensed Avastin for AMD, which is why it remains an off-label choice.
Source: National Eye Institute (NIH) — NIH study finds Avastin and Lucentis are equally effective in treating AMD (April 28, 2011), published April 28, 2011.
CMS's spending file doesn't give a clean per-eye-injection price for bevacizumab, because the same billing code covers cancer infusions at much larger doses, so we're not going to publish a dollar figure for it that we can't stand behind. What the data does show cleanly is the spread among the drugs made for the eye: a Lucentis claim averaged $889.13 in 2024 while an Eylea HD claim averaged $3,141.51 — a difference of roughly $450 in your 20%, per injection, between those two.
Source: CMS — Medicare Part B Spending by Drug (data year 2024, released June 2026), data year 2024.
- "Which drug are you planning to use, and why that one for me?"
- "How often would you expect to inject, at least to start?"
- "Is there a clinically reasonable alternative that costs less?"
- Whether to switch from Medicare Advantage to Medigap.
- Whether your plan's prior authorization will hold up next year.
- What your annual out-of-pocket ceiling actually is.
How common this is in South Dakota
CDC's Vision and Eye Health Surveillance System publishes modeled prevalence estimates by state. For South Dakota, in the most recent year in the file, data year 2019:
| Age group | Any AMD | Vision-threatening stage | South Dakotans with any AMD | With the vision-threatening stage |
|---|---|---|---|---|
| 40 and older | 14.09% | 1.11% | 58,331 | 4,606 |
| 40 to 64 | 8.1% | 0.17% | 20,999 | 447 |
| 65 to 84 | 20.91% | 1.49% | 28,844 | 2,055 |
| 85 and older | 50.84% | 12.61% | 8,484 | 2,104 |
Source: CDC — Vision & Eye Health Surveillance System (VEHSS) modeled estimates, data year 2019, crude prevalence, read from CDC's published data endpoint this week. Program background: CDC — Vision and Eye Health Data and Surveillance. These are modeled estimates with confidence intervals, not a case count.
Two things stand out. First, the jump at 85: more than half of South Dakotans that age have some form of AMD, and 12.61% have the vision-threatening stage, against 1.49% of the 65-to-84 group. Second, the state tracks slightly above the country as a whole — CDC's national estimate for adults 40 and older is 12.58% with any AMD and 0.94% with the vision-threatening stage, against South Dakota's 14.09% and 1.11%.
Source: CDC — Vision & Eye Health Surveillance System (VEHSS) modeled estimates, data year 2019, data year 2019, South Dakota and national crude prevalence.
South Dakota's population skews older than the national average in the rural counties feeding into Sioux Falls for specialty care, which fits what those numbers show. For a practical sense of scale: CMS county enrollment data for 2026 puts 39,532 Medicare beneficiaries in Minnehaha County alone. Apply CDC's 65-to-84 vision-threatening rate to a population that size and you're talking about hundreds of neighbors on an injection schedule at any given time, across Sioux Falls, Brandon, Harrisburg and Tea.
How to check your own coverage before the next shot
Five steps, in the order that makes them easiest:
Ask the retina office for the drug name and its J-code.
Every Part B drug has a billing code, and the office knows it. Write down the drug name, the code, and the planned interval between injections. Those three facts turn a vague worry into a number you can actually plan around, and they're the first thing any insurance person will ask you for.
Ask whether you'll be treated in the clinic or in a hospital outpatient department.
CMS's own coverage page says that in a hospital outpatient setting you also pay a separate facility copayment, on top of 20% of the drug and the doctor's services. Same injection, same drug, two different bills. If both options exist locally, it's a fair question to ask before the first appointment.
Find out whether your plan requires prior authorization.
If you're in a Medicare Advantage plan, the plan — not Medicare — decides whether this drug is approved and under what conditions. Ask the retina office whether they've already submitted it and whether approval is on file before you show up for the appointment.
Look up your own annual cap, or confirm you don't have one.
Original Medicare without a supplement has no annual out-of-pocket ceiling on Part B coinsurance. Medigap Plan G or Plan N changes that picture. A Medicare Advantage plan has a maximum out-of-pocket that stops the bleeding at a fixed number. Knowing which of those three you're in is most of the work.
Bring the whole thing to your annual coverage review.
A new injection schedule is one of the few health events that genuinely changes which kind of Medicare coverage fits you best. It belongs on the table during Annual Enrollment, alongside your drug list and your doctors, not six months after the first bill arrives.
If a Medicare Advantage plan denies the injection
Appeal it. KFF's data shows that only 11.5% of denied Medicare Advantage prior authorization requests were appealed in 2024, and 80.7% of those appeals came back partially or fully overturned. The retina practice will usually drive the clinical side of an appeal; we help on the coverage side, and we've done it before.
How we help
Big Sioux Benefits is a licensed independent agency in Sioux Falls. When someone calls about this, we do three specific things: read the Part B drug cost-sharing line in the plan documents for the Medicare Advantage plans we offer, check whether the retina specialist you see is in those networks, and compare that against what a Medigap policy would do to the same bill. Then we tell you what we find, including when the answer is that your current coverage already handles it fine and you should leave it alone. That conversation costs you nothing — carriers pay the agent, not you.
Big Sioux Benefits is a licensed independent insurance agency and is not connected with or endorsed by the United States government or the federal Medicare program. We do not offer every plan available in your area; any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.
What to watch in 2027
- Your Annual Notice of Change. The ANOC your plan mails every September is where a change to Part B drug cost-sharing or prior authorization rules shows up. For someone on injections, it's the single most important piece of mail of the year.
- Aflibercept biosimilars. Lower-cost versions of the molecule behind Eylea have been entering the market. If your clinic switches you to one, your 20% should move with the price — ask what changed and why.
- CMS's next Part B spending file. The figures in this guide are data year 2024, released June 2026. We'll refresh this page when CMS publishes data year 2025.
- Your own injection interval. Treatment plans get stretched or tightened based on how the eye responds. A change from every eight weeks to every four doubles the drug line in your budget.
- Network changes at Sanford and Avera. If your plan's network shifts and your retina specialist falls outside it, the cost picture changes before the drug price does.
Starting injections, or already on them?
Bring your plan card and the drug name. We'll show you exactly where the ceiling is, or whether you have one. Local, free, no pressure.
Book a conversation →How we know this: Drug dollar figures come from CMS's own Medicare Part B Spending by Drug file, data year 2024, read directly from CMS's published data endpoint. Coverage rules and the 2026 Part B deductible come from CMS's own coverage and premium pages. Prevalence comes from CDC's Vision and Eye Health Surveillance System modeled estimates for South Dakota and the nation, data year 2019. Clinical background and the AMD treatment comparison come from the National Eye Institute at NIH. Plan-level maximum out-of-pocket figures come from the carriers' own 2026 plan documents, which we opened. All of it was read on November 13, 2026. This is education, not medical or financial advice; your treatment plan belongs to you and your retina specialist. We take no payment from any carrier to feature a plan. Built with Strategic AI Architects.
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Frequently asked questions
Does Medicare cover eye injections for macular degeneration?
Yes, for the wet form. CMS states that Part B may cover certain diagnostic tests and treatments for macular degeneration, including treatment with certain injectable drugs, and that after the Part B deductible you pay 20% of the Medicare-approved amount for the drug and your doctor's services. Dry macular degeneration, the far more common form, generally has no injectable treatment to cover. The coverage is real and it's been stable for years; the part that surprises people is the 20%, which under Original Medicare alone has no annual ceiling. We walk through that math with people in the Sioux Falls area at no cost to talk.
How much does one anti-VEGF eye injection cost under Medicare in 2026?
It depends entirely on which drug. In CMS's own Part B drug spending data for 2024, the average Medicare-approved amount per claim was $1,918.34 for Eylea, $2,419.05 for Vabysmo, $3,141.51 for Eylea HD, and $889.13 for Lucentis. Your 20% coinsurance on those averages works out to roughly $384, $484, $628, and $178 per injection respectively, after you've met the 2026 Part B deductible of $283. Those are national averages from the most recent annual CMS file, not a quote for your specific clinic. Big Sioux Benefits can help you figure out what your own coverage does to that number.
Is there a limit on what I pay for eye injections under Original Medicare?
No. Under Original Medicare by itself, Part B coinsurance is 20% of the Medicare-approved amount with no annual out-of-pocket maximum, per CMS. That's the structural problem with an open-ended injection schedule: six injections a year costs you three times what two injections cost, and nothing stops the meter. A Medigap policy or a Medicare Advantage plan are the two ways to put a ceiling on it, and they work very differently. We'll lay out both for your situation, at no cost.
Does Medigap Plan G cover the 20% on eye injections?
Plan G covers the Part B coinsurance in full under CMS's standardized Medigap benefit chart, which is the 20% we're talking about here. What Plan G does not cover is the annual Part B deductible, which is $283 for 2026. So in the worked example in this guide, a year with eight Eylea injections goes from roughly $3,296 out of pocket down to the $283 deductible. Plan N covers the Part B coinsurance too, with copays of up to $20 for some office visits. We compare the Medigap plans we offer in South Dakota side by side, at no cost to you.
Will a Medicare Advantage plan cover my eye injections?
Medicare Advantage plans must cover everything Original Medicare covers, so the injections are covered, but the plan sets its own cost-sharing, its own network, and its own prior authorization rules. The upside is a hard annual ceiling: every Medicare Advantage plan has a maximum out-of-pocket, and the three Sioux Falls plans we verified directly for 2026 set theirs between $3,500 and $5,000 combined. The catch is that your retina specialist has to be in network and the drug usually has to be approved in advance. Those are exactly the two things we check for people before they enroll.
Why does my doctor use Avastin instead of Eylea for my eye?
Avastin, or bevacizumab, is a cancer drug that ophthalmologists have used off-label in the eye for close to two decades because it works and it costs a fraction of the alternatives. NIH's own Comparison of AMD Treatments Trials, covering 1,185 patients at 43 clinical centers, found Avastin as effective as Lucentis for treating AMD. The FDA has not licensed Avastin for AMD, which is why it stays an off-label choice rather than a labeled one. Which drug fits you is a medical decision for your retina specialist; what it does to your bill is the part we can help you see in advance.
Should I switch from Medicare Advantage to Medigap if I start eye injections?
It's a real question and the honest answer is that it depends on timing and on your health history. Outside your Medigap open enrollment window, South Dakota insurers can medically underwrite a Medigap application, which means a new diagnosis can affect whether you're accepted and at what rate. The Medicare Advantage out-of-pocket maximum may already be doing the job for you. This is one of those decisions worth talking through with someone local before you move anything, and that conversation with Big Sioux Benefits costs nothing.