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Your Simple Guide To Health Insurance

Understanding health insurance is complex, so we’ve simplified the basics to help you get started—including clear guidance if you’re navigating Medicare.

Insurance Options Myths vs Reality Insurance Dictionary

Medicare Summary

Insurance Options: Medicare Plans

You can choose Original Medicare or a Medicare Advantage plan.¹ View Medicare insurance options to help decide which option may be right for you.

Original Medicare includes Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). Original Medicare covers things like inpatient hospital care, doctor's services and tests, and preventive services.^1,2

Medicare Advantage often does not have a monthly premium and prescription drug coverage is usually included. This is because Medicare pays the insurance company directly to handle your health care. You will have co-payments.^1,2

STEP 1: Click below to switch between options:

Original Medicare Medicare Advantage

Original Medicare

PART A

Hospital Insurance^1,2

Part A will pay for inpatient hospital stays after a $1,676 deductible.¹

PART B

Medicare Part B usually pays 80% (after an annual deductible of $257) for covered medical services (i.e.doctor appointments, retina injections, and infusion treatments).^1,3,4

STEP 2: Determine if you need to add prescription drug coverage

PART D

Prescription Drug Coverage^1,2

Covers most prescription drugs.^1,2 Check beforehand to see if your plan covers your prescription drugs.

STEP 3: Determine if you need to add supplement insurance coverage

SUPPLEMENT INSURANCE PLAN (also known as MEDIGAP)

A type of extra insurance you can buy from a private insurance company to help you with Original Medicare (Part A and B) out-of-pocket costs.^1,2*

*Generally most supplement plans will cover the remaining 20% of retina injection costs.⁴

Medicare Advantage

PART C

Medicare Advantage Plan

A plan managed by commercial insurance companies (such as Blue Cross Blue Shield, Aetna, or UnitedHealthcare), that combines Part A, B & usually D. Your plan’s out-of-pocket costs may vary, and generally many plans pay 80% for Part B specialty drugs (retina injections).^1,2

Step 2: Determine if your Medicare Advantage plan includes drug coverage

PART D USUALLY INCLUDED

Check with your Medicare Advantage provider to confirm if you need to add prescription drug coverage.^1,2

Supplement not applicable

You cannot buy a Supplement Insurance plan while you’re enrolled in a Medicare Advantage Plan.^1,2

Medicare Advantage plans may not cover the remaining 20% of retina injection costs.^1,2*

*Individual plans may vary, please refer to your plan benefits.

Information intended for general educational purposes only. Please confirm the details of your health insurance plan with your insurance provider for the most current and accurate plan information.

Click here for a downloadable version of this information.

Commercial Summary

Insurance Options: Commercial Plans

Not 65 yet? Commercial health insurance is provided by private insurers for individuals, typically through employer-based or direct purchase plans.⁵

Many commercial health insurance plans today are structured as either a preferred provider organization (PPO) or health maintenance organization (HMO):^5,6

Preferred Provider Organization (PPO): A PPO costs more money each month, but gives you full freedom to see any doctor or specialist whenever you want without needing permission first.^5,6
Health Maintenance Organization (HMO): An HMO may keep your monthly costs lower, but you must get care from doctors and hospitals in the plan's network. You'll also choose a primary care physician (PCP) and get their permission (a referral) before seeing a specialist.^5,6

Myths vs Reality

Health insurance is a complicated system and there are a lot of misconceptions.

Click on each of the below to debunk common insurance myths.

REALITY

Depending on the plan you choose, you may still have to pay premiums, deductibles, copays, or a coinsurance.^7,8

REALITY

Retina specialist visits, in-office retina injections, and imaging may be covered differently depending on your Medicare plan.^9,10

REALITY

Plan rules, costs, covered drugs, and participating providers may change from year to year.¹¹

REALITY

It is always a good reminder to check with your insurance plan to ensure your doctor or retina specialist is in-network.

REALITY

Premium cost doesn’t always mean you get a better deal. Deductibles, copays and services covered vary depending on the plan you choose.^7,8

REALITY

Out-of-pocket costs for retina injections are often different based on your insurance plan’s coverage.^5,7

Benefits, provider networks, coverage, and cost vary depending on your specific plan. Patients should review plan materials or contact their insurance plan directly for specific plan information.

Insurance Dictionary

Here are the definitions you need to understand health insurance. Click on each box to learn what the word means.

Also called Traditional Medicare or Medicare Fee-for-Service (FFS), Medicare is the government funded health insurance program primarily for people who are 65 years or older. It includes Part A (Hospital Insurance) and Part B (Medical Insurance). Original Medicare usually covers services at 80%, like inpatient hospital care, doctor's services and tests, and preventive services.^1,2,5,12

The amount you pay every month for your insurance plan.^5,12

Example: In 2026, the Medicare Part B premium was $202.90.²

The amount you pay out-of-pocket before your plan will cover your medical service.^5,12

Once the deductible is met, you and your plan share the costs of a covered healthcare service. Your share of a covered service is called coinsurance, shown as a percent (for example, 20%) of the total amount.^2-5

A fixed amount you may pay for a covered service or prescription. This does not usually count towards your deductible amount.^5,12

Example: Your doctor's office could ask you to pay a fixed $25 fee for each visit.

The total amount you have to pay for each covered medical service.^5,12

Example: This includes your copay, deductible costs and coinsurance.

Also called out-of-pocket limit or out-of-pocket maximum, the absolute most you will have to pay out-of-pocket for covered medical services in a plan year. If you meet that amount, your health insurance plan will pay for 100% of your covered medical services for the remainder of that plan year.^5,12

Your plan may require pre-approval for a drug or service before your treatment is considered covered. Approval of your treatment is still not a guarantee of coverage.^5,12

Example: For your insurance to cover your retina injection, your doctor must submit a prior authorization request and receive approval from them before treatment.

A health insurance plan may require you to try other treatments first before they cover a specific treatment.¹³

Example: Your Medicare plan requires you to try Retina Injection A before you try Retina Injection B. If Retina Injection A is not effective, then you can try Retina Injection B.

These are hypothetical examples for illustrative purposes only. Coverage, out-of-pocket costs, and access may vary by plan.

This information is for general educational purposes only and is not a complete description of benefits. Please refer to your plan benefits and speak to your retina specialist or doctor for more information.

NEXT: Applying for Insurance

A provider network is a list of doctors, other health care providers, and hospitals that a plan contracts with to provide medical care to its members. They’re known as “in-network providers.”^5,12

The total amount you have to pay for each covered medical service^5,12

What is VABYSMO?

VABYSMO (faricimab-svoa) is a prescription medicine given by injection into the eye used to treat adults with neovascular (wet) age‑related macular degeneration (AMD), diabetic macular edema (DME), and macular edema following retinal vein occlusion (RVO).

Do not receive VABYSMO if you:

Have an infection in or around your eye.
Have active swelling around your eye that may include pain and redness.
Are allergic to VABYSMO or any of the ingredients in VABYSMO.

What is the most important information I should know about VABYSMO?

Injections like the one for VABYSMO can cause an eye infection (endophthalmitis), separation of layers of the retina (retinal detachment), or inflammation in the eye that can lead to vision loss. Call your healthcare provider right away if your eye becomes red, sensitive to light, or you have a change or loss of vision.
VABYSMO may cause a temporary increase in pressure in the eye (intraocular pressure), which occurs within 60 minutes after receiving the eye injection.
Although not common, VABYSMO patients have had serious, sometimes fatal, problems related to blood clots, such as heart attacks or strokes (thromboembolic events). In clinical studies for wet AMD during the first year, 7 out of 664 patients treated with VABYSMO reported such an event. In clinical studies for DME from baseline to week 100, 64 out of 1,262 patients treated with VABYSMO reported such an event. In clinical studies for RVO during 6 months, 7 out of 641 patients treated with VABYSMO reported such an event.
Severe inflammation of vessels in the retina has happened for patients treated with VABYSMO. Call your healthcare provider immediately if you experience a change in vision.

Before receiving VABYSMO, tell your healthcare provider about all of your medical conditions, including if you:

Are pregnant or plan to become pregnant. Based on how VABYSMO interacts with your body, there may be a potential risk to your unborn baby. You should use birth control before your first injection, during your treatment with VABYSMO, and for 3 months after your last dose of VABYSMO.
Are breastfeeding or plan to breastfeed. It is not known if VABYSMO passes into your breast milk. Talk to your healthcare provider about the best way to feed your baby if you receive VABYSMO.
Are taking any medications, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Tell your healthcare provider about all the medicines you take.

What should I avoid while receiving VABYSMO?

Your vision may be impaired after receiving an eye injection or after an eye exam. Do not drive or use machinery until your vision has recovered sufficiently.

What are the most common side effects with VABYSMO?

The most common side effects with VABYSMO were cataract and blood on the white of the eye (conjunctival hemorrhage).
These are not all the possible side effects of VABYSMO.

Call your healthcare provider for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088. You may also report side effects to Genentech at 1-888-835-2555.

Please see the VABYSMO full Prescribing Information for additional Important Safety Information.

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