Choosing the Insurance Coverage That’s Right for You

For many Insurance companies, open enrollment period closes December 7, 2025.

If your treatment in Dr. Jones’ office includes high-cost injections (such as Eylea, Eylea HD, Vabysmo, Syfovre, or Izervay), the type of insurance you have is an important consideration to ensure that this treatment is the most affordable for you.

If your insurance plan has a high deductible, the high cost of your eye injections means that each year, you will most likely have to meet that high deductible amount before your insurance begins to cover the cost of your injections or any other medical care you receive. This could cost you hundreds or even thousands of dollars out-of-pocket. Your doctors’ offices will expect immediate and complete payment for services until your deductible is met.

If you are UNDER 65

If you are under 65, you are likely insured under a plan that you have selected yourself or through your employer. You may want to consider changing to a plan with a low deductible. While the monthly premiums may be somewhat higher, a lower deductible means less out-of-pocket cost for you when you receive an expensive treatment.

If you are 65 OR OLDER

Your insurance coverage is likely either through a Medicare Advantage Plan (Medicare Part C), or through Original Medicare parts A and B (your ‘primary’ insurance). You may also have Medigap coverage (your ‘secondary’ insurance). Regardless of the coverage you have, you may want to review your coverage so that you are aware of all of your out-of-pocket costs, which may include co-pays and deductibles.

Many Part C Advantage Plans require “prior authorization” in order to use expensive drugs. Even after prior authorization, the patient may be left with large charges under the title of “co-insurance” and co-pay. Some insurers will not authorize your doctor’s use of certain medications, even though they are the best treatment for you. If this is the case, the patient bears full responsibility for the cost of these treatments, which could be thousands of dollars.

If you have only Medicare Parts A and B (your ‘primary’ insurance), your insurance will cover only 80% of your doctor office bills, and will not cover any co-pays. The patient or secondary insurance is responsible for the remaining 20% of all treatment costs as well as all co-pays. 

Medigap coverage (a ‘secondary’ insurance policy) will pay the remaining 20% of your bills as well as any co-pays. Depending on the Medigap coverage you choose, deductibles from Medicare Part B (office visits) may also be either partially or completely covered. While adding on a monthly premium, having secondary insurance coverage may reduce your overall annual costs for doctors’ office visits and treatments including costly injectables.

If you have questions, you may also reach out to our staff by calling 410 288-2853