Summary: Medicare spending, per-patient costs, and real-world utilization

Anti-VEGF agents for macular degeneration account for a large share of Medicare Part B drug spending. In 2024, fee-for-service Medicare spent $3.0 billion on Eylea (including Eylea HD) for 329,500 users and $1.9 billion on Vabysmo for 173,300 users; Eylea ranked second and Vabysmo sixth among all Part B products, with average spending per user of $9,200 and $11,100. Across 2014 to 2023, Medicare fee-for-service beneficiaries received 36,398,293 intravitreal anti-VEGF injections, and aflibercept use increased from 618,796 injections in 2014 to 1,713,729 in 2023.

In U.S. commercial claims (6,076 participants), mean annual all-cause cost was $24,520 per patient, and nAMD-related outpatient visit costs were $8,658 for active choroidal neovascularization compared with $2,406 for inactive disease. A prevalence-based model estimated per-annum costs of $55,752 per person with nAMD in the United States when productivity and well-being losses are included. Vision loss of all causes cost the United States an estimated $134.2 billion in 2017.

Real-world injection counts are lower than in registration trials: a mean of 7.3 injections in year 1 in the Vestrum database (49,485 eyes), 6.0 in U.S. electronic health records, and 7.2 in year 1 falling to 4.2 to 4.6 per year in years 3 to 6 in the IRIS Registry. In these data, visual acuity outcomes increased with injection count, and in the IRIS Registry mean visual acuity was 4.6 letters below baseline after 6 years.

Medicare Part B spending on macular degeneration drugs, 2024

Product	Total drug spending, billions	Number of users	Average spending per user	Percent change in total spending, 2023 to 2024
Eylea (includes Eylea HD)	“3.0”	“329,500”	“9,200”	“–4”
Vabysmo	“1.9”	“173,300”	“11,100”	“48”

“Medicare spending (including beneficiary cost sharing) on the top 10 products accounted for $22.4 billion, or 34 percent of total Part B drug spending.” (opens the source at this quote in a new tab)
“The top 20 also include 3 products for arthritis, autoimmune disease, or inflammatory bowel disease and 2 products for macular degeneration.” (opens the source at this quote in a new tab)
“Average spending per user ranged from $13,000 to $39,000 for three drugs used to treat arthritis, autoimmune disease, or inflammatory bowel disease, and from $9,000 to $11,000 for two drugs used to treat macular degeneration.” (opens the source at this quote in a new tab)
“Between January 2025 and 2026, four products experienced a price decrease: Eylea, Vabysmo, Rituxan, and Entyvio.” (opens the source at this quote in a new tab)

Medicare Part B spending on macular degeneration drugs, 2023

Product	Total drug spending, billions	Number of users	Average spending per user	Percent change in total spending, 2022 to 2023
Eylea	“3.1”	“341,800”	“9,200”	“–11”
Vabysmo	“1.3”	“112,600”	“11,500”	“N/A”
Avastin (indications include macular degeneration)	“0.6”	“161,500”	“3,700”	“–14”
Lucentis	“0.5”	“91,600”	“5,900”	“–32”

Medicare anti-VEGF injection volume and reimbursement per injection, 2014 to 2023

“From 2014 to 2023, a total of 36 398 293 intravitreal anti-VEGF injections were administered to Medicare beneficiaries.” (opens the source at this quote in a new tab)
“Aflibercept use increased significantly (618 796 injections in 2014 vs. 1 713 729 in 2023; τ = 0.91; P < 0.001).” (opens the source at this quote in a new tab)
“Faricimab demonstrated rapid early uptake after its introduction in 2022 (65 052-556 512 injections).” (opens the source at this quote in a new tab)
“Standardized Medicare reimbursement per injection declined significantly for ranibizumab ($1234.35-$724.74; τ = -1.00; P < 0.001) and aflibercept ($1527.37-$1379.54; τ = -0.82; P = .001), remained stable for brolucizumab, and increased for bevacizumab ($46.76-$300.73; τ = 0.69; P < 0.01).” (opens the source at this quote in a new tab)

On-label versus off-label anti-VEGF use and Part B spending by community, 2013 to 2023

“From 2013-2023, 5,178 providers billed Part B for 34.5 million anti-VEGF injections.” (opens the source at this quote in a new tab)
“Equalizing anti-VEGF mix to that of the highest-poverty quartile would have resulted in approximately $4.2 billion lower spending.” (opens the source at this quote in a new tab)

Anti-VEGF injection trends in Medicare Part B, 2013 to 2021

“Among 26 602 816 total injections performed from 2013 to 2021, relative usage of aflibercept increased by 158.3%, while relative usage decreased by 27.5% for ranibizumab and 49.6% for bevacizumab.” (opens the source at this quote in a new tab)
“Step therapy has not significantly increased bevacizumab usage on an aggregate level.” (opens the source at this quote in a new tab)

Medicare Part B spending per beneficiary on ranibizumab and aflibercept, 2011 to 2015

“During this 5-year period, associated Medicare drug costs averaged $1.3 billion annually.” (opens the source at this quote in a new tab)
“Annual Medicare drug expenditure for aflibercept was $1.4 billion on average.” (opens the source at this quote in a new tab)
“On average, Medicare spent $9719 and $9934 annually on each beneficiary receiving ranibizumab and aflibercept injections, respectively.” (opens the source at this quote in a new tab)
“Ranibizumab and aflibercept costs account for 12% of the Medicare Part B budget annually.” (opens the source at this quote in a new tab)

Estimated Medicare and patient savings from bevacizumab use, 2008 to 2015

“The use of bevacizumab from 2008 to 2015 resulted in an estimated savings of $17.3 billion, which corresponded to a $13.8 billion savings to Medicare and a $3.5 billion savings to patients.” (opens the source at this quote in a new tab)

Manufacturer payments to ophthalmologists and Medicare Part B spending, 2013 to 2019

“Ophthalmologists who accepted manufacturer payments were significantly less likely to prescribe bevacizumab (28.0% [95% CI, 24.6%-42.5%] of patients) compared with those who did not accept manufacturer payments (45.8% [95% CI, 44.5%-47.1%]).” (opens the source at this quote in a new tab)
“Had ophthalmologists who accepted manufacturer payments prescribed ARMD drugs as those who did not accept payments, Medicare spending on these treatments would have been $642 779 703.08 lower from 2013 to 2019, a 2.0% savings.” (opens the source at this quote in a new tab)

Direct costs and resource use by disease activity: U.S. commercial claims

“A total of 6,076 patients with nAMD were identified for the prevalent cohort; 60.1%, 17.2%, and 5.9% had active CNV, inactive CNV, and inactive scar disease stage at index, respectively.” (opens the source at this quote in a new tab)
“The nAMD-related outpatient visit costs were roughly 4 and roughly 7 times higher, respectively, for the active CNV group ($8,658 [SD = $11,612]) compared with the inactive CNV ($2,406 [SD = $5,510]) and inactive scar ($1,198 [SD = $3,035]) groups (P < 0.0001).” (opens the source at this quote in a new tab)
“About 10% of prevalent patients had a fall/fracture claim over 12 months of follow-up.” (opens the source at this quote in a new tab)
“A total of 3,623 prevalent patients (59.6%) were eligible for the anti-VEGF treatment patterns analysis (mean [SD] duration of therapy = 7.7 [4.5] months; mean [SD] number of injections = 6.0 [3.7]).” (opens the source at this quote in a new tab)

“Mean (SD) annual total all-cause cost for the prevalent cohort was $24,520 ($43,950) with outpatient costs as the largest cost component (63.5%; Supplementary Figure 2 (577KB, pdf) , available in online article).” (opens the source at this quote in a new tab)
“Multivariate GLM results revealed an increasing trend in costs with increasing anti-VEGF injection frequency; there were 73% higher costs for patients with 4-6 injections to 342% higher costs for those with 10 or more injections compared with those with 1-3 injections over 1 year of follow-up (P < 0.0001).” (opens the source at this quote in a new tab)

Outpatient visit type, prevalent cohort	All patients	Active CNV	Inactive CNV	Inactive scar
All-cause visits, mean (SD)	“30.6 (26.4)”	“31.0 (25.5)”	“27.5 (25.3)”	“27.1 (25.9)”
nAMD-related visits, mean (SD)	“6.6 (4.8)”	“7.7 (4.6)”	“4.1 (3.5)”	“2.9 (2.9)”
Anti-VEGF-related visits, mean (SD)	“3.9 (4.2)”	“5.1 (4.2)”	“1.3 (2.5)”	“0.5 (1.6)”

Real-world injection frequency and per-patient cost: ranibizumab and aflibercept in U.S. claims

“After adjusting for patient demographics and clinical characteristics, per-patient injection frequency and cost were not significantly different between treatment-naive patients with nAMD who received ranibizumab versus aflibercept over 12 months (5.62 vs. 5.54; P = 0.52, and $11,351 vs. $10,702; P = 0.06, respectively) and 24 months (7.86 vs. 8.37; P = 0.16, and $16,286 vs. $16,666; P = 0.69, respectively).” (opens the source at this quote in a new tab)
“Most patients received fewer injections than any FDA-indicated dosing schedule, suggesting potential undertreatment that may result in suboptimal vision outcomes.” (opens the source at this quote in a new tab)

Medicare Part B payments in the first year after nAMD diagnosis, 1994 to 2006 cohorts

“Overall yearly Part B payments per beneficiary increased significantly from $3,567 for the 1994 to $5,991 for the 2006 cohort (p<0.01) in constant 2008 dollars.” (opens the source at this quote in a new tab)
“Payments for eye care alone doubled from $1,504 for the 1994 cohort to $3,263 for the 2006 cohort (p<0.01).” (opens the source at this quote in a new tab)
“Most of the increase in payments for eye care in 2006 reflected payments for anti-VEGF injections, which were $1,609 over 1 year.” (opens the source at this quote in a new tab)

Societal cost of late-stage AMD in the United States, Germany, and Bulgaria

“Estimated per-annum total costs attributable to late-stage AMD were €449.5 million ($512.5 million) in Bulgaria, €7.6 billion ($8.6 billion) in Germany, and €43.2 billion ($49.4 billion) in the US.” (opens the source at this quote in a new tab)
“Across all countries, 10% to 13% of the total cost incurred was attributed to direct medical costs.” (opens the source at this quote in a new tab)
“In Germany and Bulgaria, the biggest contributor to the total economic burden was reduced well-being (67% and 76%, respectively), whereas in the US, loss of productivity (42%) was the biggest contributor.” (opens the source at this quote in a new tab)

“In nAMD, the loss of productivity accounted for 46% of the total cost, and in GA, it accounted for 36%.” (opens the source at this quote in a new tab)
“The financial costs incurred due to nAMD amounted to €17.2 billion ($19.7 billion) and totaled €13.4 billion ($15.3 billion) for GA (Table 3).” (opens the source at this quote in a new tab)
“Per-annum individual costs incurred due to nAMD and GA were estimated at €48 895 ($55 752) and €39 250 ($44 755), respectively (Table 4).” (opens the source at this quote in a new tab)

Economic burden of vision loss and blindness in the United States (2017)

“We estimated an economic burden of VL of $134.2 billion: $98.7 billion in direct costs and $35.5 billion in indirect costs.” (opens the source at this quote in a new tab)
“The largest burden components were NH ($41.8 billion), other medical care services ($30.9 billion), and reduced labor force participation ($16.2 billion), all of which accounted for 66% of the total.” (opens the source at this quote in a new tab)
“Those with VL incurred $16 838 per year in incremental burden.” (opens the source at this quote in a new tab)
“Informal care was the largest burden component for people 0 to 18 years of age, reduced labor force participation was the largest burden component for people 19 to 64 years of age, and NH costs were the largest burden component for people 65 years of age or older.” (opens the source at this quote in a new tab)

Lost gross domestic product attributable to AMD in the United States

“An economic analysis based upon losses to the gross domestic product suggests that ARMD has approximately a $30 billion annual negative impact.” (opens the source at this quote in a new tab)

“The total yearly loss to the GDP due to lost wages from neovascular ARMD among all affected people is therefore $2.866 billion + $2.530 billion = $5.396 billion.” (opens the source at this quote in a new tab)

Work productivity loss in AMD: meta-analysis

“Seven studies consisting of 3,060,864 subjects from 5 different countries were included in this systematic review.” (opens the source at this quote in a new tab)
“Mean wages lost due to impaired work productivity ranged from $1,395 to $55,180.” (opens the source at this quote in a new tab)
“The mean unemployment rate attributed to AMD ranged from 5.50% to 77.00%.” (opens the source at this quote in a new tab)

Modeled direct and indirect costs of extended-interval agents: aflibercept 8 mg versus faricimab (United States)

“Direct costs were estimated based on modeled mean injection numbers and 2025 wholesale acquisition costs per injection (aflibercept 8 mg: 2677.50 USD; faricimab: 2289.65 USD) plus medical monitoring costs.” (opens the source at this quote in a new tab)
“Over a 3-year time horizon, the mean number of injections was lower with aflibercept 8 mg versus faricimab for nAMD (12.25 vs. 14.80 injections) and DME (11.80 vs. 15.65 injections).” (opens the source at this quote in a new tab)
“Total costs (direct and indirect) associated with aflibercept 8 mg were 1978.74 USD lower than faricimab for nAMD and 6032.90 USD lower than faricimab for DME.” (opens the source at this quote in a new tab)

Real-world injection frequency and visual acuity: Vestrum Health Retina Database (United States)

“In this analysis, 49 485 eyes were included.” (opens the source at this quote in a new tab)
“At 1 year, after a mean of 7.3 anti-VEGF injections, there was a mean gain of 1 letter (0.95 letter; 95% confidence interval [CI] for change in VA, +0.77 to +1.13 letter; P < 0.001).” (opens the source at this quote in a new tab)
“There was a linear relationship between mean letters gained and mean number of injections, between 4 and 10 injections over 1 year, with 4 or fewer or 10 or more injections associated with loss of vision or a plateau, respectively.” (opens the source at this quote in a new tab)
“Real-world nAMD patients receive fewer anti-VEGF injections and experience worse visual outcomes compared with patients receiving fixed, frequent therapy in randomized controlled trials.” (opens the source at this quote in a new tab)

Visits, injections, and visual acuity in U.S. electronic health records

“Over the first 12 months, patients made a mean of 8.1 (range, 1-39) ophthalmologist visits, received a mean of 6.0 (range, 1-27) anti-VEGF injections, and underwent 7.2 OCT and 5.3 FA examinations per study eye.” (opens the source at this quote in a new tab)
“Mean change from baseline VA at 12 months increased linearly with cumulative anti-VEGF injection count: +1.79 versus -0.95 approximate ETDRS letters for eyes receiving 7 or more injections versus fewer than 7 injections.” (opens the source at this quote in a new tab)

Six-year injection frequency, discontinuation, and visual acuity: U.S. IRIS Registry

“A cohort of 254 655 eyes (226 767 patients) with first anti-VEGF injection and at least 2 years of follow-up; 160 423 eyes had visual acuity (VA) data.” (opens the source at this quote in a new tab)
“After a mean VA increase of 3.0 ETDRS letters at year 1, annual decreases led to a net loss from baseline of 4.6 letters after 6 years.” (opens the source at this quote in a new tab)
“From a mean of 7.2 in year 1 and 5.6 in year 2, mean injections plateaued between 4.2 to 4.6 in years 3 through 6.” (opens the source at this quote in a new tab)
“Treatment was discontinued in 38.8% of eyes and switched in 32.3%.” (opens the source at this quote in a new tab)
“Of the patients, 58.5% lost ≥ 10 letters VA at least once during follow-up, with 14.5% of patients experiencing sustained poor vision after a median of 3.4 years.” (opens the source at this quote in a new tab)

First-year injection counts by agent: U.S. IRIS Registry

“Of 13 859 patients, 6723 received bevacizumab, 2749 received ranibizumab, and 4387 received aflibercept only for 1 year.” (opens the source at this quote in a new tab)
“The mean number of injections (standard deviation) at 1 year was higher in the ranibizumab (6.4 [±2.4]) and aflibercept groups (6.2 [±2.4]) compared to bevacizumab group (5.9 [±2.4]; P < 0.0001).” (opens the source at this quote in a new tab)

Real-world injection frequency and visual acuity: eight-country AURA study

“2227 patients who received ≥1 anti-VEGF injection with a baseline visual acuity assessment and ≥1 postbaseline visual acuity assessment for the treated eye were evaluated.” (opens the source at this quote in a new tab)
“Mean change in visual acuity score from baseline to years 1 and 2 was +2.4 and +0.6 letters, respectively.” (opens the source at this quote in a new tab)
“Patients received a mean of 5.0 and 2.2 injections in the first and second year, respectively.” (opens the source at this quote in a new tab)

Causes of undertreatment in routine practice: literature review

“In real-world practice, patients are usually undertreated, accounting for the VA decline over time.” (opens the source at this quote in a new tab)
“Reasons for undertreatment include the burden of injections and monitoring visits imposed on patients/caregivers.” (opens the source at this quote in a new tab)

Blindness incidence and healthcare system impact after anti-VEGF introduction: systematic review

“Population-based analyses reported reduction in incidence among the general population of 47% (9.1 cases/100,000 in 2006 to 4.8 cases/100,000 in 2011).” (opens the source at this quote in a new tab)
“The introduction of anti-VEGF led to increased overall treatment costs due to replacement of existing less frequently administered treatments (e.g. photodynamic therapy) and increased number of patients treated (prior to anti-VEGF, only ~ 20% of patients were eligible for treatment).” (opens the source at this quote in a new tab)

Societal cost of bilateral nAMD: five-country observational study (2005 euros)

“In the previous 12 months, 12-22% of patients fell, and half of these patients required medical treatments.” (opens the source at this quote in a new tab)
“The average annual societal cost per bilateral NV-AMD patient treated was estimated to be euro 7879 in Canada, euro 7349 in France, euro 12 445 in Germany, euro 5732 in Spain and euro 5300 in the UK, and direct vision-related medical costs accounted for 23-63% of the total cost.” (opens the source at this quote in a new tab)

Annual healthcare utilization costs versus controls: UK cohort

“Total annual healthcare utilisation costs were more than sevenfold higher for patients with AMD compared with controls (£3,823.89 vs £517.05, respectively; p<0.0001)” (opens the source at this quote in a new tab)

Patient-centered incremental costs, including out-of-pocket costs: South Korea

“We identified 931 patients with exudative AMD and matched 783 (84.1%) with 2918 patients with nonexudative AMD.” (opens the source at this quote in a new tab)
“In the exponential conditional model, the total medical, reimbursement, nonreimbursement, and out-of-pocket incremental costs were estimated at US $3426, US $3130, US $366, and US $561, respectively, in the first year and US $1829, US $1461, US $373, and US $507, respectively, in the second year.” (opens the source at this quote in a new tab)

Vision impairment due to AMD: Global Burden of Disease 2021

“Globally, the number of individuals with vision impairment due to AMD more than doubled, rising from 3·64 million (95% uncertainty inverval [UI] 3·04-4·35) in 1990 to 8·06 million (6·71-9·82) in 2021.” (opens the source at this quote in a new tab)
“Similarly, DALYs increased by 91% over the same period, from 0·30 million (95% UI 0·21-0·42) to 0·58 million (0·40-0·80).” (opens the source at this quote in a new tab)

Five-year trend in first-year injection numbers by initial anti-VEGF agent, United States

“In 2012, there were 6.7 yearly injections, 7.3 yearly injections, and 7.2 yearly injections on average in the groups initially treated with bevacizumab, aflibercept, and ranibizumab, respectively.” (opens the source at this quote in a new tab)
“By 2016, the mean number of yearly injections in the groups initially treated with bevacizumab and ranibizumab had increased by approximately 1, to 7.8 and 8.0 yearly injections, respectively.” (opens the source at this quote in a new tab)

Injection visits and dosing schedules in routine care: multinational survey including the United States

“Within 12 months, nAMD patients attended more visits where anti-VEGF injections were administered (nAMD: mean = 7.74, SD = 3.63; DME: mean = 6.54, SD = 3.40).” (opens the source at this quote in a new tab)
“One-third of DME (33.9%) and one-quarter of nAMD patients (25.8%) were on a fixed treatment schedule, with 73.6% (n = 120 of 163) receiving injections every ≤8 weeks.” (opens the source at this quote in a new tab)
“About one-third of nAMD (38.1%) and one-quarter of DME (26.8%) patients were on a treat-and-extend (T&E) regimen, with 69.7% (n = 138 of 198) receiving injections every ≤8 weeks.” (opens the source at this quote in a new tab)

Retina practice staff time devoted to neovascular AMD management: U.S. time-and-motion study

“The results of the retina specialist survey showed that on average, 23 staff members were involved in the management of neovascular AMD patients, including the receptionist, the office manager, the billing manager, technicians, and other physicians or staff (Table).” (opens the source at this quote in a new tab)
“The management of patients with neovascular AMD accounted for an average of 20% of the staff’s time per work week: most technicians (68%) spent more than 20% of their time, one-quarter of office managers spent more than 10% of their time, and more than one-third (37%) of billing managers spent more than 20% of their time managing patients with neovascular AMD (Figure 2).” (opens the source at this quote in a new tab)
“Although these preparatory steps were typically performed concurrently, the average total staff time spent on all preparation steps was 43 minutes.” (opens the source at this quote in a new tab)

State-level variation in Medicare anti-VEGF injection rates, 2023

“West Virginia had the lowest overall injection rate at 5723/100 000 Medicare beneficiaries, whereas Alaska had the highest rate at 180 838/ 100 000, representing a 31.6-fold difference.” (opens the source at this quote in a new tab)
“For aflibercept, Alaska recorded the highest injection rate at 68 241/100 000, whereas Hawaii had the lowest at 2602/100 000, resulting in a 26.2-fold difference.” (opens the source at this quote in a new tab)
“Faricimab utilization ranged from 207/100 000 in Vermont to 10 247/100 000 in Nebraska, a 49.4-fold difference.” (opens the source at this quote in a new tab)
“Bevacizumab use was the highest in Alaska at 93 497/100 000 and lowest in West Virginia at 630/100 000, representing a 148.3-fold difference.” (opens the source at this quote in a new tab)

Total Medicare anti-VEGF expenditure and per-beneficiary utilization, 2014 to 2023

“From an economic perspective, total Medicare expenditures for anti-VEGF therapy rose from approximately $2.5 billion USD in 2014 to $3.7 billion USD in 2023, despite declining reimbursement per injection for aflibercept and ranibizumab.” (opens the source at this quote in a new tab)
“This increase was primarily driven by rising injection volumes and the introduction of newer branded agents (faricimab and brolucizumab).” (opens the source at this quote in a new tab)
“To summarize per-100 000-beneficiary utilization, aflibercept increased from 1864/100 000 to 5997/100 000 beneficiaries (221% rise)” (opens the source at this quote in a new tab)
“Faricimab increased from 219/100 000 to 1947/100 000 between 2022 and 2023 (789% rise), whereas brolucizumab declined from 142 to 18 per 100 000 (87% decline).” (opens the source at this quote in a new tab)

AXPAXLI (axitinib intravitreal implant)

Economic burden and healthcare resource utilization