The following information provides general advice on the bill you will receive from your ophthalmologist for eye injections for the management of wet macular degeneration, diabetic retinopathy and similar conditions. It also gives some general information on your entitlements from Medicare.
As ophthalmologists are entitled to set their own fees, this fact sheet cannot provide specific information or precise rebates for your individual situation.
You should ask your ophthalmologist for written details on the fees and charges you will incur for consultations, tests and treatment. You should also feel free to discuss any aspect of the fees, including Medicare rebates and likely out-of-pocket costs. If the costs are going to place you under financial difficulty and possibly compromise your treatment plan, you should discuss this with your doctor.
The fees you pay may involve up to four areas: consultation, diagnostic tests, drug costs and injection costs. In some cases (especially for diabetic retinopathy), you may also be billed for laser treatment. Your ophthalmologist may list and describe the items and cost on the bill in varying ways.
In the information below, the term ‘doctor’ means the ophthalmologist.
When you first visit the doctor for a specific condition, the consultation will appear as Medicare item 104 - Initial consultation.
Ongoing consultations will appear as Medicare item 105 - Subsequent consultation.
Note that from 1 Nov 2017, item 105 cannot be used (ie there is no Medicare rebate) if you are also receiving a procedure (such as an eye injection or laser) on the same day.
Fundus fluorescein angiography, also known as angiogram or FFA
This will be itemised as Medicare item 11215 (one eye) or item 11218 (two eyes) - Retinal photography, including intravenous dye examination)
This test checks for bleeding or leakage under the retina. It may beis required before you first start injections in order to qualify for Pharmaceutical Benefits Scheme (PBS) reimbursement of the drug that is used to treat the bleeding or leakage. It may also be done to check for new leakage.
Optical coherence tomography (OCT)
An OCT scan shows the cross-sectional layers of the retina and is initially performed to confirm a diagnosis and measure how much swelling has occurred. OCT scans will typically be undertaken on a regular basis while on a course of injections in order to monitor response to treatment. OCT scans are now internationally recognised as the standard of care to monitor response to injections. Up to one OCT scan per year may be reimbursed by Medicare, but only when the scan is performed by an ophthalmologist for an initial diagnosis to confirm eligibility for PBS-funded eye injections. OCT scans for ongoing monitoring of disease are not currently reimbursed by Medicare.
For many years the Foundation has been advocating that Medicare coverage for OCT should be expanded to include ongoing monitoring. We continue to make representation to Government on this issue.
Depending on individual needs, other tests may be undertaken.
The cost of the drug is in addition to the diagnostic and injection fees.
Lucentis and Eylea
The drugs Lucentis and Eylea are registered by the Therapeutic Goods Administration (TGA) and are subsidised by the Pharmaceutical Benefits Scheme (PBS) for the treatment of:
- Wet age-related macular degeneration (AMD)
- Diabetic macula edema (DME)
- Retinal vein occlusion (RVO)
Under the PBS, the subsidised cost of these drugs per prescription (one dose) is:
- $6.40 (concession card holder); or
- $39.50 (non-concession)
The PBS Safety Net will apply once the costs in a calendar year for all PBS drugs exceed $384.00 (concession) or $1,521.80 (non-concession). After reaching the PBS Safety Net, each subsequent PBS script will be free (concession) or $6.40 (non-concession) for the remainder of the calendar year.
For those who do not qualify for PBS subsidised drugs, the drug Avastin may be used. Avastin is not registered by the TGA for use in the eye. This is known as “off-label” use and it is not subsidised by the PBS for these conditions. The cost of Avastin typically ranges between $50 and $80 per dose.
Either of two Medicare items may be used for the injection procedure:
Medicare item 42738 – Intra-vitreal injection: This may appear on the bill as “Paracentesis” or “Injection”.
Medicare item 42739 – Intra-vitreal injection: This item number will be used if you require sedation or a general anaesthetic, where an anaesthetist is present. This may also appear on your bill as “Paracentesis” or “Injection”.
In some cases, laser treatment may be used in which case it will appear as Medicare item 42809 - Retina photocoagulation.
Medicare provides significant benefits (rebates) for many of the items related to eye injections. The benefit is normally paid:
- in doctors’ rooms: as 85% of the ‘schedule fee’
- in a private hospital or day case setting: as 75% of the ‘schedule fee’.
- From 1 Nov 2017, item 105 cannot be used (ie there is no Medicare rebate) if you are also receiving a surgical procedure (such as an eye injection or laser) on the same day
- For injections in both eyes on the same day, the benefit for the second eye is reduced by 50%. If two eyes are treated on separate days, the normal benefits apply
- OCT scans are not currently listed as a Medicare item and do not attract any Medicare benefit.
Original Medicare Safety Net
The difference between the schedule fee and the benefit paid by Medicare is known as the ‘gap amount’.
The ‘gap amount’ for an eye injection given in the doctor’s rooms is currently $45.10. This is calculated as the schedule fee ($300.75) minus Medicare benefit ($255.65). (Refer to Table 1)
Once the total gap amount for all non-hospital Medicare items exceeds the Original Medicare Safety Net threshold* in a calendar year, the Original Medicare Safety Net will refund 100% of the schedule fee for subsequent non-hospital Medicare items. For example, for Item 42738 (Injection fee), you would receive a benefit of $300.75.
* The Original Medicare Safety Net threshold is set by the Australian Government and changes from time to time. In 2018 the threshold is $461.30.
Costs may vary between doctors and doctors may charge more than the Medicare schedule fee. The difference between what the doctor charges and the Medicare benefit is known as the ‘out-of-pocket’ cost. This is not the same as the ‘gap amount’. For example, if a doctor charges $400 for an in-rooms injection (item 42738), the out-of-pocket costs for this will be $144.35 per Table 2 below.
If the Original Medicare Safety Net has also been reached, the out-of-pocket costs would be further reduced. Extended Medicare Safety Net: Once the total out-of-pocket costs for all non-hospital Medicare items exceed a certain threshold^ in a calendar year, the Extended Medicare Safety Net (EMSN) will refund the relevant Medicare benefit PLUS a further benefit of 80% of out-of-pocket costs for non-hospital Medicare items.
^ The Extended Medicare Safety Net thresholds are set by the Australian Government and change from time to time. From 1 January 2018, the thresholds for out-of-pocket costs are:
- Concession card holders: $668.10
- Non-concession: $2,093.30
Using the same charges as Table 2, once the EMSN threshold has been reached, the total benefit paid for the injection (item 42738) would equal the normal Medicare benefit of $255.65 plus the EMSN benefit of $115.50 (being 80% of the out-of-pocket amount of $144.35), giving a total benefit of $371.15. This means you would only pay $28.85 for that item after you have received all the rebates.
(OOP = out of pocket)
If the Original Medicare Safety Net had also been reached, the benefits would be slightly higher. For some procedures, including eye injections, the EMSN benefits are capped. For items 42738 (and 42739) the EMSN benefit is capped at a doctor’s fee of $556.40. The EMSN rebate of 80% of out-of-pocket costs will not apply to the portion of the doctor’s fee above $556.40.
- Non-Medicare items such as OCT scans do not attract any Medicare benefits and do not contribute towards the Original or Extended Medicare Safety Net threshold.
- Procedures performed in a private hospital or day surgery setting do not contribute towards the Original or Extended Medicare threshold and do not receive the additional benefits.
Registration for Medicare Safety Net
Couples and families need to register as a Medicare Safety Net family, even if all are listed on the same Medicare card. Medicare will automatically keep a total of your gap amounts and out-of-pocket medical expenses. Registration is free and you only need to register once in your lifetime.
To register for the Medicare Safety Net:
Department of Veterans’ Affairs (DVA) patients
DVA gold card holders may qualify for some additional rebates, including Optical Coherence Tomography (OCT) scans.
Treatment in hospital
Treatment in public hospitals
A limited number of public hospitals provide outpatient treatment for conditions including macular degeneration and diabetic retinopathy. There should be no charge for treatment and diagnostic tests, although in some states, there may be a requirement to pay the PBS co-contribution if Lucentis or Eylea are used ($6.40 concession or $39.50 non-concession).
Treatment in private hospitals
In some situations, a doctor may decide to give injections in a private hospital or day surgery setting. People who hold private health insurance may be able to claim from their private health fund for the procedure and accommodation charge. This is dependent on the insurer and the policy.
- Injections are typically required for an extended period (many years), and possibly for life.
- You should obtain a written estimate of fees, Medicare benefits and out-of-pocket costs from your doctor.
- If you have financial difficulty with treatment costs, discuss your concerns with your doctor or the appointed person in the practice.
- Treatment should not be stopped without discussion with the doctor. There may be a number of challenges with maintaining treatment, including costs or transport or other health issues.
- Discuss your concerns with your doctor.
If you require further information, clarification or guidance on eye injection treatment and benefits or related matters please telephone the Foundation's free Helpline: 1800 111 709.