Medical-Surgical Eye Care: Balancing Clinical Integrity with Cost Efficiency

Blog

Health Network One

Published on: 09-16-2025

Managing specialty care has become one of the biggest challenges facing health plans today, and eye care is no exception. Retinal diseases are rising in both prevalence and cost, with much of the financial burden driven by expensive biologic medications.

But health plans don’t have to choose between protecting members’ vision and protecting their budgets. With the right strategy, it’s possible to do both. Step therapy within medical-surgical eye care offers a proven, evidence-based approach that ensures members receive safe, effective treatment while driving measurable savings for health plans.

Retinal Diseases, and Their Costs, are Rising

As our population ages and diabetes becomes more prevalent, diseases of the eyes, like age-related macular degeneration (AMD), retinal vein occlusion (RVO), and diabetic macular edema (DME), are becoming more common. When not properly managed, these conditions can progress to irreversible blindness, creating devastating consequences for members and costly burdens for health plans.

These diseases are also among the most expensive to treat, posing a growing financial challenge for health plans. Without strategic management, costs for these conditions can escalate rapidly, impacting both plan budgets and member affordability.

Medicare Plans Bear the Brunt of Treatment Costs

Among those aged 50 and older, retinal diseases are one of the leading causes of blindness.¹ Data published in 2021 shows that AMD alone affects nearly 20 million Americans² while RVO and DME affect an additional 3 million Americans.^3,4

Because aging and diabetes are the primary risk factors, it should be no surprise that Medicare is the single largest payer of care for these costly eye conditions.⁵ AMD alone costs Medicare $3.5 billion annually,⁶ and this number is expected to continue to climb as our population ages.

Medications are the Largest Cost Driver

Currently, the most effective treatments for AMD, RVO, and DME are intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections. Depending on the disease and the medication, injections may be required as often as every four weeks after the initial treatment.

While these medications are effective at delaying disease progression, they are also the largest driver of cost. Several brand name options, like Eylea^® and Lucentis^®, cost approximately $2,000 per injection. Therefore, a full year’s treatments can easily cost health plans as much as $26,000 per eye. And for members, who are likely to have out-of-pocket costs for these treatments, the copays or coinsurance quickly add up.

However, with a strategic program to manage medical and surgical eye care, health plans can support cost-effective treatments for AMD, RVO, and DME while also helping members achieve optimal visual outcomes. It’s a win-win solution for both plans and members.

Effective Treatments at Lower Cost with Step Therapy

When clinically appropriate, an alternative anti-VEGF medication – proven to be effective in treating AMD, RVO, and DME – can be used as a first-line treatment at a price of only $100 per injection. This approach, known as step therapy, is a key component of Health Network One’s medical-surgical eye care solution.

Step therapy is a clinically accepted method of managing prescription drug usage, and it’s allowed by the Centers for Medicare & Medicaid Services for Part B medications. Step therapy requires that treatments start with the most effective, lowest cost option suited for each member’s condition. If the initial medication is ineffective or not tolerated, providers can then prescribe the higher cost drug.

For retinal conditions like AMD, RVO, and DME, Avastin^® (bevacizumab) is the recommended first-line treatment. It’s been in use as an off-label anti-VEGF treatment for more than 20 years, and multiple clinical trials have demonstrated its effectiveness.7,8 It’s also available for a fraction of the cost of newer drugs. By implementing step therapy for anti-VEGF medications, Health Network One has helped health plans save $1.6 million per 100,000 members.

Smart Protocols That Balance Cost and Care

Despite the savings and proven efficacy of Avastin^® in treating these retinal diseases, step therapy does have some detractors. For example, some may say that effective treatment is delayed if the first-line option is ineffective, and treatment delays can lead to member frustration.

At Health Network One, our protocols, refined over more than 30 years, help us identify cases that are not likely to be suited for step therapy. Members who meet certain conditions, such as those with DME and vision worse than 20/50, can start immediately with the anti-VEGF treatments recommended by their providers.

Optimize Your Medical-Surgical Eye Care

When not carefully managed, medical eye benefits often result in lower utilization of cost-effective treatments like Avastin^®, despite strong clinical evidence supporting its use. In fact, Medicare averages around a 40% Avastin^® utilization rate, which means plans are likely spending significantly more on anti-VEGF medications than they need to.

In contrast, Health Network One’s protocols achieve nearly 70% Avastin^® utilization, delivering huge savings without compromising care. For one client, the switch from 37% Avastin^® utilization as a first-line treatment to 70% utilization under our protocols saved the plan nearly $5 million annually. Across all lines of business, our medical management model consistently drives savings of 20% to 40%, helping health plans control costs while ensuring members receive effective, evidence-based treatment.

Because health plans can change medical-surgical eye care benefits at any time, your plan can start saving now – without compromising care. Make medical-surgical eye care work for your health plan. Discover your savings potential by requesting a custom analysis today. https://healthnetworkone.com/analysis