DME Access Barriers: Anti-VEGF Costs, Prior Authorizations, and Coverage Denials

In "DME Access Barriers: Anti-VEGF Costs, Prior Authorizations, and Coverage Denials," our experts turn to the financial obstacles that stand between patients and effective therapy.

Dr. Yannuzzi closes the previous thought by noting that treatment burden contributes to poor outcomes in many patients. He then moves to a second barrier and asks Dr. Patel how he navigates the cost of anti-VEGF therapy, which can limit access to care.

Dr. Patel calls cost one of the biggest challenges that retina specialists and their patients face. The price of these treatments keeps rising, and so does the cost of insurance. Coverage for these medications is sometimes limited, depending on the patient's plan.

He adds that earlier-generation treatments are sometimes not enough to control the disease or to keep the treatment burden manageable. That creates a difficult conversation when a physician wants to change therapies, because the better option may be harder for the patient to obtain.

Dr. Patel describes a heavy administrative load on the practice side as well. Physicians must write prior authorizations to get patients onto the most appropriate and effective treatments. Even with that effort, denials still occur.

When that happens, the practice must work with patients, with its social work office, and with rebate programs. It may also turn to extra funding programs run through other organizations to get medications covered. Dr. Patel concludes that cost is a major limiting factor for care.

He also raises a more basic problem. Even holding insurance does not guarantee access, and many patients have no insurance at all. Those patients have trouble getting the care they need in the first place, before any questions about agent selection or coverage arise.

Dr. Yannuzzi acknowledges these as great points. Together, the two physicians describe a system in which rising drug prices, limited plan coverage, prior authorization work, and denials stack on top of the burden patients already carry.

Up next, in "DME Extended-Interval Anti-VEGF: Improving Adherence and Choosing the Right Agent," the experts discuss how longer dosing intervals reshape patient motivation and how Dr. Patel chooses among agents.