Does Medicare cover Eylea in North Carolina?

What Eylea is used for

Eylea 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 retinopathy of prematurity. Eylea HD is a higher-dose version with its own label.

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

Which part of Medicare covers Eylea

Medicare.gov explains that Part B covers most injectable and infused drugs when a licensed medical provider gives them, and usually covers drugs you wouldn't typically give yourself, given in a doctor's office or hospital outpatient department. Eylea fits exactly: the retina practice buys the drug, injects it and bills Medicare for the drug and the visit. That's why Eylea doesn't appear on Part D formularies the way pills and pens do.

Is Eylea on Medicare's negotiated-price list?

No. Eylea is not among the drugs CMS has selected for the Medicare Drug Price Negotiation Program so far: the 10 drugs with negotiated prices since January 1, 2026, the 15 with negotiated prices starting January 1, 2027, and the 15 CMS selected on January 27, 2026, for prices that take effect in 2028 (the first round that could include Part B drugs).

Biosimilars

FDA approved the first aflibercept biosimilars, Yesafili and Opuviz, in May 2024, both rated interchangeable with Eylea, and has licensed more since; FDA's Purple Book lists them. Your retina specialist decides which product to use. Under Part B, a biosimilar is covered under the same rules as Eylea.

What you pay for Eylea 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. Original Medicare has no yearly out-of-pocket limit, and injections every few weeks add up.
• Medigap: every standardized Medigap plan, including Plan A, pays some or all of the 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. The list of those drugs changes every quarter.

CMS publishes the 2027 Part B deductible with its yearly Part A and Part B fact sheet; see Medicare costs in 2027. The Part D cap ($2,400 in 2027), the Medicare Prescription Payment Plan and Extra Help apply to Part D drugs, not to Eylea given in your doctor's office.

Eylea in North Carolina: Original Medicare, Medigap or Medicare Advantage

Ongoing eye injections are where the choice between Original Medicare and Medicare Advantage shows up most. With Original Medicare you can see any retina specialist who accepts Medicare, but the coinsurance has no yearly limit unless you have Medigap or other coverage. With Medicare Advantage you use the plan's network and may need prior authorization, but in-network costs are capped. Every North Carolina county has Medicare Advantage plans open to everyone for 2027, from 11 in Carteret County to 57 in Guilford County. Before you pick a plan, check that the retina specialist you see is in its network. See your county.

North Carolina's Medigap rules. North Carolina has no Medigap birthday rule or yearly switching right. Your one-time, 6-month Medigap open enrollment period starts when you're both 65 and enrolled in Part B; outside it, and outside a guaranteed-issue right, a Medigap company can ask health questions and can turn you down. If your Medicare Advantage plan is ending in 2027, you have a guaranteed right to buy certain Medigap plans for 63 days after it ends. See Medigap in North Carolina and plans ending in 2027.

Under 65 with diabetic eye disease? If you have Medicare because of a disability, G.S. 58-54-45 requires Medigap companies to offer you at least Plan A, without regard to your health, if you apply in the six months after you enroll in Part B (and Plan D or G if the company sells those to people 65 and older). Plan A pays the Part B coinsurance. See Can I get Medigap under 65 in North Carolina?

State Health Plan retirees. On the 70/30 Plan, Medicare pays first and the Plan may help pay some of the costs Medicare doesn't. The Plan says that if you don't have Part B, it pays as if Part B had paid, so keep Part B. On the Base Plan or Enhanced Plan (group Medicare Advantage), Part B drugs follow the Plan's rules. See State Health Plan retirees and Medicare.

Limited income. MQB-Q, North Carolina's name for the Qualified Medicare Beneficiary program, pays Part B deductibles and coinsurance as well as the premium; the county Department of Social Services handles applications. See Medicare Savings Programs in North Carolina.

Checking your coverage for Eylea

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 for 2027.
2. Ask about prior authorization. Medicare Advantage plans may require approval, or a trial of another drug first (step therapy), before covering Eylea. The doctor's office usually handles the request.
3. Know who pays your coinsurance. Find out whether Medigap, a Medicare Advantage plan's out-of-pocket limit, the State Health Plan or MQB-Q covers your Part B share.
4. Compare before December 7. If you're changing coverage for 2027, look at eye-care networks rather than drug formularies, since Eylea isn't on a Part D formulary. You can request a call from a licensed insurance agent, who can compare plans from the companies they work with, 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: Eylea prescribing information (FDA label)
• Medicare.gov — Prescription drugs (outpatient) under Part B
• Medicare.gov — Medigap (Medicare Supplement Insurance)
• FDA — FDA approves first interchangeable biosimilars to Eylea (May 2024)
• FDA — Purple Book: licensed biological products, biosimilars and interchangeables
• CMS — Selected drugs and negotiated prices (Medicare Drug Price Negotiation Program)
• CMS — Selected drugs for initial price applicability year 2028 (fact sheet, January 2026)
• CMS — CY 2027 Rate Announcement (2027 Part D threshold; Medicare Advantage out-of-pocket limits)
• North Carolina General Statutes — Chapter 58, Article 54, Medicare Supplement Insurance Minimum Standards
• North Carolina General Statutes — G.S. 58-54-45, Medigap for people eligible for Medicare by reason of disability
• Medicare.gov — Medicare Savings Programs
• NC Medicaid — MA-2252, Non-MAGI income and reserve limits (MQB-Q, MQB-B, MQB-E), effective April 1, 2026
• State Health Plan — 2027 plan comparison for Medicare-primary members
• State Health Plan — Retiree presentation (Part B and the 70/30 Plan)
• CMS — Medicare Advantage and Part D Landscape files, 2027 (North Carolina county plan counts)

Frequently asked questions

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