Does Medicare Cover Ozurdex?

Ozurdex is an expensive medication, so many people rely on their healthcare insurance to pay for their treatment. Below, you can find out whether Medicare covers Ozurdex and how much you'll pay for care. 

What Is Ozurdex?

Ozurdex is a small corticosteroid implant used to treat macular edema, including diabetic macular edema, and noninfectious uveitis. It works by slowly dissolving to release medication over time, removing the need for regular eye injections. A doctor administers an Ozurdex implant by injecting it into the back of your eye. 

Ozurdex implants contain dexamethasone, which reduces inflammation to improve your eyesight. As the implant dissolves, you won't need a separate procedure to remove it. 

Ozurdex Side Effects

Infection is a potential complication of having an Ozurdex implant, so your doctor will monitor you closely after insertion. Other possible side effects include:

• Eye pressure
• Headache
• Eye soreness and redness
• Cataracts
• Floaters
• Retinal tears
• Ocular hypertension

Does Medicare Cover Ozurdex?

Typically, you'll need Medicare Part D (prescription drug coverage) to receive coverage for prescription-only medications. However, Medicare Part B may cover injectable drugs, such as Ozurdex, in an outpatient setting because you can't administer the medication yourself. Therefore, you may receive coverage through Original Medicare if your doctor verifies your treatment is medically necessary. 

However, you may not be entitled to coverage of Ozurdex specifically. According to the CMS, Medicare covers a similar dexamethasone implant called Dextenza, but it's unclear whether it will cover other brands. Therefore, it's worth asking your doctor whether another brand is suitable if you can't obtain Ozurdex coverage. 

It's unclear how many Medicare Part D plans cover Ozurdex. However, these plans are unlikely to cover Dextenza, so the same issues may apply to Ozurdex. You can find out whether your policy covers Ozurdex by checking the formulary, which is the list of covered drugs.

How Much Does Ozurdex Cost With Medicare?

How much you'll pay for an Ozurdex implant depends on whether you're eligible for coverage through Medicare Part B. If you are, you must first meet your deductible, which is $240 as of 2024. Medicare pays 80% of the approved amount for your treatment after you meet the deductible, and you're responsible for paying the remaining 20%. 

If you're ineligible for coverage through Part B and your Part D plan covers your treatment, you'll usually pay the total cost of your treatment until you meet the Part D deductible. Deductibles vary by insurer but can't exceed $545. Once you've met your deductible, your insurer assumes responsibility for covering the costs, minus a co-pay.

Does Medicare Restrict Ozurdex Coverage?

You must meet Medicare's eligibility criteria for Ozurdex implants (or a similar brand) before receiving coverage through Part B. Your doctor must verify that the treatment is medically necessary. Similarly, your Medicare Part D plan may require prior authorization, which means your doctor must contact your insurer to certify the necessity of your treatment.