What Medicare covers for Miebo

Miebo is not covered by Original Medicare Part B, and most Medicare Advantage plans do not cover it either. Miebo (perfluorohexyloctane) is a newer prescription eye drop used to treat dry eye disease, and it falls into a category of drugs that Medicare typically does not pay for through its standard medical insurance.

If your doctor prescribes Miebo, you will pay the full cost out of pocket unless you have a separate prescription drug plan (Part D) or your Medicare Advantage plan includes drug coverage. Even then, coverage is not may provide — it depends on which specific plan you have and whether that plan's formulary (the list of drugs it covers) includes Miebo.

The reason for limited coverage is that Miebo is expensive and relatively new. Medicare moves slowly in adding newer medications, especially when older, cheaper alternatives exist for the same condition. Your out-of-pocket cost for a month's supply of Miebo typically ranges from $300 to $400 without insurance, though this varies by pharmacy.

Key Takeaways

  • Original Medicare Part B does not cover Miebo, and you will need to check your specific Part D or Medicare Advantage plan to see if it is included.
  • If your plan does cover Miebo, you will likely pay a copay or coinsurance rather than the full retail price of $300 to $400 per month.
  • Older dry eye medications like artificial tears, cyclosporine (Restasis), and lifitegrast (Xiidra) are more commonly covered by Medicare plans.
  • Your doctor can request a coverage exception or prior authorization from your plan if Miebo is medically necessary and other treatments have not worked.
  • Patient information programs run by the manufacturer may reduce your cost if your plan does not cover the drug.

How to check if your plan covers Miebo

The fastest way to find out is to call the customer service number on the back of your insurance card. Have your plan name and member ID ready. Ask specifically whether Miebo is on your formulary and what your copay or coinsurance would be.

If you have Original Medicare with a separate Part D plan, call your Part D plan's customer service line — not Medicare directly. Part D plans are run by private insurance companies, and each one has its own formulary. Two people on Original Medicare may have completely different coverage for the same drug depending on which Part D plan they chose.

If you have a Medicare Advantage plan (Part C), that plan usually includes prescription drug coverage, but again, you need to check that specific plan's formulary. Many Medicare Advantage plans post their formularies online, or you can request one by phone.

What to do if your plan does not cover Miebo

If Miebo is not covered and your doctor believes it is the right treatment for you, ask your doctor to submit a prior authorization request to your insurance plan. This is a formal request asking the plan to make an exception and cover the drug. Your doctor will need to explain why Miebo is medically necessary — usually because you have already tried other dry eye treatments and they did not work.

Prior authorization requests take one to two weeks in most cases. Your plan may approve it, deny it, or approve it with conditions (such as requiring you to try a cheaper drug first). If your plan denies the request, your doctor can appeal the decision, though this adds more time.

Another option is to ask your doctor about older dry eye medications that Medicare plans cover more readily. Cyclosporine (Restasis) and lifitegrast (Xiidra) are both covered by most Medicare plans and work for many people with dry eye disease. These are not newer, but they are proven treatments.

Patient information programs and discount cards

The manufacturer of Miebo, Bausch + Lomb, runs a patient information program that may reduce your cost if your insurance does not cover the drug or if you have a high copay. You can contact them directly or ask your pharmacy for information about the program.

Discount prescription cards like GoodRx and SingleCare sometimes offer lower prices on Miebo than the retail price at your pharmacy. These are not insurance — they are negotiated discounts that you can use even if you have Medicare. It is worth checking these cards before paying full retail price, though the discount is usually smaller than what insurance would pay.

Be aware that using a discount card instead of your insurance may affect your Part D deductible and out-of-pocket maximum calculations. Ask your Part D plan before using a discount card, especially early in the year when you are still working toward your deductible.

Other dry eye treatments Medicare covers

If Miebo is not covered and a prior authorization is denied, Medicare plans typically cover these alternatives for dry eye disease:

  • Artificial tears and lubricating ointments — over-the-counter, usually not covered by insurance but inexpensive (a few dollars per bottle)
  • Cyclosporine (Restasis) — prescription eye drop, covered by most Medicare plans, requires several weeks to work
  • Lifitegrast (Xiidra) — prescription eye drop, covered by most Medicare plans, also requires several weeks to work
  • Warm compresses and eyelid cleaning — non-drug treatments your doctor can recommend at no cost
  • Punctal plugs — a minor procedure to block tear drainage, covered by Medicare Part B when medically necessary

Your eye doctor can discuss which of these options might work for your specific type of dry eye. Some people benefit from combining treatments rather than relying on one medication alone.

When to ask your doctor about coverage

Before your doctor writes a prescription for Miebo, tell them you have Medicare and ask whether the drug is likely to be covered. Your doctor's office may already know which medications their Medicare patients' plans typically cover, and they can suggest alternatives if Miebo is unlikely to be paid for.

If your doctor has already prescribed Miebo and you have just found out it is not covered, contact your doctor's office right away. They can either submit a prior authorization request or switch you to a covered medication. Do not wait until you run out of the prescription.

Frequently Asked Questions

Can I use a GoodRx coupon instead of my Medicare Part D?

Yes, you can use a discount card, but check with your Part D plan first. Using a discount card does not count toward your deductible or out-of-pocket maximum, which may cost you more in the long run if you take other medications. Compare the GoodRx price to what your Part D copay would be before deciding.

What if my Medicare Advantage plan covers Miebo but the copay is very high?

Ask your plan whether Miebo is on a higher tier (which means a higher copay). If it is, your doctor can request a prior authorization or ask the plan to move it to a lower tier based on medical necessity. You can also ask about the manufacturer's patient information program to help with the copay.

Does Original Medicare Part B cover any eye drops?

Original Medicare Part B covers eye drops only if they are given as part of an office visit or procedure — for example, dilating drops during an eye exam. Prescription eye drops you take home are covered by Part D (prescription drug coverage), not Part B. You need a separate Part D plan to have them covered.

How long does a prior authorization take?

Most Medicare plans respond to prior authorization requests within one to two weeks. Some plans may take longer if they need more information from your doctor. Ask your doctor's office for a timeline when they submit the request, and follow up if you do not hear back within two weeks.

Will my plan cover Miebo if I have already tried other dry eye drops?

It depends on your specific plan, but many plans are more likely to approve Miebo if you can show that you have already used other treatments without success. Your doctor will need to document this in the prior authorization request. This is called a "step therapy" requirement, and it is common for newer, more expensive medications.