Questions on Valeda for AMD: Insurance Coverage
Regarding the status of coverage for PBM, it is now routinely covered by Medicare across the country for intermediate dry AMD with visual acuity between 20/32 and 20/70. Intermediate AMD, for this purpose, is defined as 3 or more intermediate drusen or one large druse. It is not covered for early or advanced disease, or if an eye has ever been treated for exudative, or wet AMD. This is not to say that patients with early or advanced disease (dry AMD) do not benefit from PBM treatment, simply that medicare does not cover it. At the present time, coverage by other payors, including advantage plans, is extremely variable. More often then not, it is not covered. The only way to know for sure if your treatment will be covered is to have your claim for treatment submitted to the payor, which is always an option for the patient.
If Medicare covers it for those eligible, why don't all the Medicare Advantage plans cover it? Are they just better plans in general?
Hi
. Medicare Advantage is a private alternative to Medicare, offered through through health insurance companies. Though the basic coverage should be the same, that's not always the case. It's hard to say which is better. It really depends on your individual needs. - Lori (Team Member)
Many patients refer to them as 'disadvantage' plans, as coverage is usually much more restrictive. The cost is lower, but many plans restrict which providers you can see. In the case of PBM, at the present time, it is often not covered by Advantage plans.
