Does Medicare Cover Restasis? 

Dry eyes are often just a minor annoyance. Most people who experience the symptoms of dry eyes can either alleviate symptoms through natural blinking or by using over-the-counter eye drops. Others, however, experience dry eyes on a regular and ongoing basis. When this happens, the condition may be called chronic dry eye syndrome. Seniors who experience chronic dry eye syndrome may need their doctors’ help to find relief.

If you’re eligible for Medicare and experiencing chronic dry eyes, talk to your doctor. There may be solutions available to help reduce your discomfort and protect your eyes.

What causes chronic dry eye syndrome?

Chronic dry eye syndrome, often referred to as chronic dry eye, can be caused by a number of things, including aging and the use of contact lenses. Diseases of the eye may also lead to chronic dry eye. Both prescription and over-the-counter medications can facilitate the development of this condition as well.

It’s important to note that chronic dry eye differs from dry eyes which are the result of eye irritation or tiredness. Like people of any age, many seniors use computers and smart devices on a daily basis. The use of screens can lead to tired eyes that get dry after a while. Chronic dry eye syndrome causes symptoms like pain and itching even when there is no direct irritation affecting the eyes.

How is chronic dry eye treated?

Treatment options for chronic dry eye vary based on the severity of the condition and its cause. If a specific medication is leading to symptoms, your doctor may discontinue your prescription or switch you to a different medication.

If contact lenses are to blame, your eye doctor may recommend changing your eye care routine or switching to a different brand of lenses. In other cases, medications like Restasis (ciclosporin) may be prescribed to help your body make more of its own natural tears to alleviate irritation and inflammation.

Does Medicare cover Restasis?

Medicare coverage is available for prescription medications through Medicare Part D. This coverage is optional, so it is something that you will need to opt for when signing up for Medicare benefits. You can get Part D during your Initial Enrollment Period or during an annual enrollment period. Medicare Part D covers prescription medications that can be purchased from retail pharmacies, and all covered medications must be designated for use at home.

If you have Original Medicare, you can enroll in a stand-alone Part D Prescription Drug Plan. As an alternative, you can choose to enroll in a Medicare Advantage plan that includes prescription drug coverage. 

Medicare Part D may cover Restasis if your doctor believes that the drug is medically necessary and no suitable alternative treatment covered by Medicare benefits exists. Medicare insurance only covers items that are deemed medical necessities, and the program does not offer coverage for standard vision care. Restasis must also be listed on your plan’s formulary, or list of covered drugs.

Restasis and Outpatient Care

Outpatient care, meaning care administered during an appointment at your doctor’s office or in a medical clinic, is covered by Medicare under Part B. If Restasis is administered in an outpatient setting, Medicare recipients will usually receive 80% coverage by Medicare. The remaining 20% is a coinsurance cost that will be billed to the Medicare recipient receiving care, and a deductible applies to all Part B plans.

Restasis and Inpatient Care

Medicare coverage for inpatient care, meaning hospital admission or admission to a skilled nursing facility, is provided through Medicare Part A. If you are admitted to a Medicare-participating inpatient facility and Restasis is administered, the medication may be covered by your Medicare benefits under Part A. Medicare Part A only provides coverage for a limited amount of days of inpatient care per year, and you must meet your plan’s deductible in order to begin using your benefits.