Use of Bevacizumab for AMD Resulted in Savings of $17.3B for Medicare, Patients

Philip J. Rosenfeld, MD, PhD

A study has determined that the use of intravitreal anti-vascular endothelial growth factor (anti-VEGF) agent bevacizumab (Avastin, Genentech/Roche) to treat exudative age-related macular degeneration (AMD) in contrast to other intravitreal anti-VEGF agents has resulted in extensive savings for both patients, and the Medicare system, in the United States.

Led by Philip J. Rosenfeld, MD, PhD, a Professor of Ophthalmology at Bascom Palmer Eye Institute, University of Miami Health System, he and colleagues reported that between 2008 and 2015, the use of bevacizumab for treatment of AMD has saved Medicare an estimated $13.8 billion, and patients an estimated $3.5 billion.

Despite a lack of US Food and Drug Administration (FDA) approval for the use of bevacizumab in intravitreal anti-VEGF treatments for AMD, bevacizumab has become the preferred option for treatment of AMD for Medicare patients due to its cost.

The treatments average approximately $60-$70 per dose, while other anti-VEGF agents used for the treatment of AMD, such as ranibizumab (Lucentis, Genentech/Novaris) and aflibercept (Eylea/Zaltrap, Regeneron), can cost up to $2000 per dose. Bevacizumab, like ranibizumab and aflibercept, has been proven effective in multiple studies for the treatment of AMD, but its use is considered off-label, according to the FDA.

Intravitreal anti-VEGF treatments for AMD often follow monthly or bimonthly injection regimens, meaning that the overall cost to Medicaid and customers is high. Rosenfeld wrote that when injected according to FDA label indications, “ranibizumab would be administered monthly at an annual drug cost of about $24,000, and aflibercept, which is dosed monthly for 3 injections, followed by bimonthly injections has an annual cost of $12,000 once the first 3 injections are given.”

According to the study, the use of intravitreal bevacizumab to combat AMD curtails costs further when combined with current clinical pro re nata and treat-and-extend (TREX) regimens which are individualized based on patient optical coherence tomography (OCT) images to reduce the frequency of injections.

Rosenfeld wrote that “OCT-guided strategies are used for all 3 anti-VEGF drugs” and refers to a study by Mathew A. Windsor, PhD, Senior Manager of Science Communications at the Association for Research in Vision and Ophthalmology.

Windsor's study revealed that the use of OCT to guide individualization of intravitreal anti-VEGF regimens saved an estimated $2.2 billion between 2008 and 2015. Rosenfeld pointed out that OCT-guided therapy helped patients avoid “17.7 million unnecessary injections between 2008-2015.”

In order to gather data on the cost savings connected to the use of bevacizumab, Rosenfeld and colleagues utilized data from the free-to-access Medicare Provider Utilization and Payment Data 2012-2015: Physician and Other Supplier Public Use Files (Physician and other Supplier PUF), and previously published data from 2008’s 100% fee-for-service (FFS) Part B Medicare Claims File, provided by the Center for Medicare and Medicaid Services (CMS).

Rosenfeld and colleagues analyzed all anti-VEGF drug claims identified by treatment codes for AMD. Rosenfeld wrote that “using the costs of bevacizumab, ranibizumab, and aflibercept between 2008 and 2015 and knowing the total number of doses injected during this time, we calculated the total cost for each drug in each year [and calculated cost savings] on an 80:20 percentage split between Medicare and beneficiaries, respectively.”

The off-label use of bevacizumab for the treatment of AMD, according to Rosenfeld and colleagues, saved approximately $17.3 billion, but savings related to bevacizumab could be much higher if the study had included “other diagnostic indications such as diabetic macular edema and retinal vein occlusion” or “Medicare beneficiaries using Medicare Advantage plans or private insurance.”

Rosenfeld predicted that the inclusion of these additional factors would see cost savings in excess of $30 billion.

Rosenfeld argued that although the savings resulting from the use of OCT-guided intravitreal bevacizumab regimens for AMD in the US are remarkable, the low-cost and widespread availability of bevacizumab suggests that “the amount saved in the US is just a fraction of the global cost-savings from these breakthrough imaging and treatment strategies.”

Despite the fact that bevacizumab's use for treatment of AMD is off-label, it remains the most commonly prescribed anti-VEGF agent for AMD treatment, and despite its comparatively low cost, its effectiveness is comparable to other anti-VEGF agents.

The study, “Estimating Medicare and Patient Savings from the use of bevacizumab for the treatment of exudative age-related macular degeneration,” was published in the American Journal of Ophthalmology.