Experts recommend that people with diabetes get a comprehensive eye exam every year to monitor for developments such as diabetic retinopathy, which can cause changes in vision.
The most common cause of vision loss in people with diabetic retinopathy is diabetic macular edema (DME). Nearly 4% of people with diabetes who are 40 years old or older have DME. It’s important to know what treatments your insurance plan will cover so you can plan ahead.
1. Does diabetic macular edema qualify for disability?
In some cases, DME can cause significant vision loss. If that happens, you may qualify for disability benefits because the condition has significantly affected your ability to see and work.
However, when you apply for disability benefits, you may have to provide paperwork from your doctor. You’ll need to show evidence that DME has affected your vision so much that you cannot work.
2. Is macular degeneration covered by medical insurance?
Many, if not most, major health insurance plans should cover care for macular degeneration because it’s an eye disease. Many plans will also cover DME, but the amount of coverage will vary from plan to plan.
If you have Medicare, it will cover an annual diabetic eye exam. Medicare Part B will cover certain diagnostic tests and treatment for macular degeneration. Medicare will also cover care for DME. Your cost may depend on where you receive care, how much your doctor charges, and any other insurance coverage you may have.
3. Can you get disability for macular edema?
You can probably get disability benefits for macular edema if you can show that it has significantly affected your ability to do your job.
Your eligibility may also depend on the extent of your DME. For example, if the condition has affected or reduced your vision, you may not be able to see and write as well as you once did. If you have severe central vision loss, you may not be able to drive or navigate certain environments either.
4. What is the FDA-approved treatment for diabetic macular edema?
Your insurance company may require you to receive treatment that is specifically approved for DME by the Food and Drug Administration (FDA). If that’s the case, you have some options.
The standard first-line treatment for DME is anti-vascular endothelial growth factor therapy (anti-VEGF therapy). This treatment is given as a series of injections into your eye of medications such as aflibercept or ranibizumab.
However, you can work with your doctor to consider other options. The FDA has also approved focal photocoagulation as a treatment for DME — in fact, that method was used before the approval of anti-VEGF injections. But it does have some limitations — for example, it will not improve your vision.
Implants that deliver corticosteroids to your retina can also be helpful.
5. How to find resources and support
You can start by talking with your doctor, who may have some suggestions about resources for financial assistance.
The National Institute of Diabetes and Digestive and Kidney Diseases maintains a list of potential resources to help with the costs of diabetes care. For example, you may qualify for financial assistance from one of these organizations:
Drug manufacturers often offer patient assistance programs, so that may be another avenue to consider.
You may also be able to apply for coverage from nonprofits and private foundations.
For example, the Pan Foundation provides financial assistance of up to $2,100 per year for people with macular diseases if they meet the list of qualifications and the fund is accepting applications.
Good Days also offers financial assistance to people with macular diseases if they have Medicare or military insurance and meet other eligibility requirements. For FDA-approved treatments, you might be able to receive up to $4,200.
The PAF Co-Pay Relief Program may be another option to investigate for help with paying for treatments.
Insurance plans and insurance coverage vary widely, so it’s hard to know exactly what treatment you should choose for DME until you do some research. Your doctor can help you determine which treatments are most appropriate for you. Then you can find out what your insurance plan will cover.
If your insurance doesn’t cover enough of the cost, you may want to look into patient assistance programs or other resources that may be able to help you afford the cost of this vision-saving treatment.