Cost, coverage, and access challenges in geographic atrophy treatment

In the final episode of this Special Report series, Joseph A. Anaya, MD, MBA, and Ashkan M. Abbey, MD, FASRS, FAAO, discuss financial access and real-world considerations surrounding treatment for geographic atrophy (GA), focusing on insurance coverage, patient affordability, and how clinicians approach conversations about treatment value.

Cost remains a legitimate concern for many patients, particularly given the chronic and progressive nature of GA. The disease can cause substantial functional impairment, including declines in reading ability, loss of driving independence, increased fall risk, and greater reliance on caregivers. Abbey explains that delaying central involvement, even by a year or a year and a half, may provide meaningful value for patients and the health care system. However, financial barriers within the current insurance infrastructure often complicate treatment access.

For patients with Medicare coverage but without supplemental insurance, out-of-pocket costs can be significant. Abbey explains that both available therapies are expensive, and patients with only Medicare Part B or Medicare Advantage coverage may face costs of approximately $400 to $450 per eye per treatment. For patients requiring treatment in both eyes, this can approach $800 to $900 every one to two months.

Historically, clinicians have relied on nonprofit financial assistance programs such as Good Days to help cover the remaining costs not paid by Medicare. Abbey notes that funding from Good Days has frequently run out quickly in recent years, limiting access for many patients. More recently, the program created a separate funding pool for non-vascular retinal diseases, including GA and MacTel, which may help improve access as additional funds are directed specifically toward these conditions, Abbey notes. However, the program is still ramping up, and some patients remain on waiting lists for approval.

Abbey notes that if patients must personally cover the full out-of-pocket cost, he often advises against starting treatment, noting that paying $800 to $900 regularly is generally not sustainable without financial assistance. Instead, he typically helps patients enroll in the Good Days program and proceeds with treatment if coverage is approved.

Despite these challenges, the clinicians highlight that therapies for GA represent an important step forward. Although current evidence demonstrates stronger anatomic outcomes than functional visual improvements, having an available treatment marks a meaningful shift in managing a disease that previously offered few options for patients.

Ashkan M. Abbey, MD, FASRS, FAAO, is in practice at Texas Retina Associates in Dallas, Texas, and director of clinical research. He is a speaker and consultant for Apellis Pharmaceuticals, Inc and Astellas Pharma Inc.

Joseph A. Anaya, MD, MBA, is assistant professor of ophthalmology at Wilmer Eye Institute at Johns Hopkins University School of Medicine in Baltimore, Maryland. He has no relevant financial disclosures.