Does Medicare cover Lucentis in Oregon?

What Lucentis is used for

Lucentis is an anti-VEGF drug injected into the eye. Its FDA label covers wet (neovascular) age-related macular degeneration, macular edema after retinal vein occlusion, diabetic macular edema, diabetic retinopathy and myopic choroidal neovascularization.

This page explains Medicare coverage only. Questions about whether Lucentis is right for you belong with your prescriber.

Which part of Medicare covers Lucentis

Lucentis is a Part B drug: your ophthalmologist or retina specialist gives the injection and bills Medicare for the drug and the procedure. You won't find it on a Part D formulary, and the Part D tools (the out-of-pocket cap, the Medicare Prescription Payment Plan and Extra Help) don't apply to it.

Is Lucentis on Medicare's negotiated-price list?

Lucentis is not among the drugs CMS has selected for the Medicare Drug Price Negotiation Program so far (the 10 drugs with negotiated prices for 2026, the 15 for 2027 and the 15 selected in January 2026 for 2028).

Generics and biosimilars

FDA licensed Byooviz (ranibizumab-nuna), the first biosimilar to Lucentis, in September 2021, and Cimerli (ranibizumab-eqrn), rated interchangeable, in August 2022. Your doctor chooses the product; Part B covers a biosimilar under the same rules.

Lucentis in a Medicare Advantage plan

If you have a Medicare Advantage plan, it must cover everything Part B covers, including Lucentis, but it can manage how. Plans may require prior authorization, may use step therapy for Part B drugs (for example, asking that a different anti-VEGF drug be tried first) and limit you to in-network eye doctors. If your plan denies a request, your doctor can ask for an expedited decision when waiting could harm your sight. See appealing a denial. If your plan is ending in 2027, plan ahead so treatment isn't interrupted; see plans ending in 2027.

What you pay for Lucentis under Part B

Part B drug costs work differently from Part D:

• Original Medicare: after the yearly Part B deductible, you generally pay 20% of the Medicare-approved amount for the drug and for the visit. There's no yearly out-of-pocket limit in Original Medicare.
• Medigap: a Medigap policy can pay some or all of that Part B coinsurance, depending on the plan letter.
• Medicare Advantage: the plan sets its own cost sharing for Part B drugs, and in-network spending is capped by the plan's yearly maximum out-of-pocket limit (no higher than $9,850 in-network in 2027). Plans may require prior authorization or step therapy for Part B drugs.
• Inflation rebates: Medicare.gov notes you may pay lower coinsurance for certain Part B drugs whose prices rise faster than inflation. CMS updates that list every quarter.

The Part D out-of-pocket cap ($2,400 in 2027), the Medicare Prescription Payment Plan and Extra Help apply to Part D drugs, not to Lucentis given in your doctor's office. If your income is limited, a Medicare Savings Program can help with Part B costs: the QMB program pays Part B deductibles and coinsurance. See Medicare Savings Programs in Oregon.

Lucentis in Oregon

Part B covers Lucentis the same way in every Oregon county. What varies is how you get the rest of your coverage. CMS data show no Medicare Advantage plan open to everyone in Grant, Harney, Lake, Umatilla or Union counties for 2027, and only a special needs plan in Curry County, so people there who need ongoing eye injections generally rely on Original Medicare, with or without Medigap. Check your county.

If you have OHP and Medicare, OHP can help pay Medicare cost sharing, and people in the QMB program pay no Part A or Part B deductibles, coinsurance or copays, according to the Oregon Health Authority. See OHP and Medicare. If you already have Medigap, Oregon's birthday rule (OAR 836-052-0143) lets you switch to a policy with the same or lesser benefits from 30 days before to 30 days after your birthday without health questions.

Checking your coverage for Lucentis

1. Confirm your eye doctor takes your coverage. With Original Medicare, ask whether the practice accepts Medicare assignment. With Medicare Advantage, confirm the retina specialist is in the plan's network.
2. Ask about prior authorization. Medicare Advantage plans may require approval, or a step-therapy trial of another drug, before covering Lucentis. The doctor's office usually handles the request.
3. Know how your coinsurance is paid. Find out whether your Medigap plan, a Medicare Advantage plan's out-of-pocket limit, or a Medicare Savings Program covers the Part B share.
4. Compare before December 7. If you're changing coverage for 2027, look at eye-care networks, not drug formularies, since Lucentis isn't on a Part D formulary. You can request a call from a licensed insurance agent, or call 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048) for information on all of your options.

Sources

• National Library of Medicine — DailyMed: Lucentis prescribing information (FDA label)
• Medicare.gov — Prescription drugs (outpatient) under Part B
• FDA — Purple Book: licensed biological products, biosimilars and interchangeables
• Medicare.gov — Appeals in Medicare drug plans (coverage determinations and exceptions)
• Medicare.gov — Medigap (Medicare Supplement Insurance)
• CMS — Selected drugs and negotiated prices (Medicare Drug Price Negotiation Program)
• CMS — Selected drugs for initial price applicability year 2028 (fact sheet, January 2026)

Frequently asked questions

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