“If I have an approved drug that the patient has full coverage for, but it costs the government $2,000 every time, I can explain that to them,” Welch said by telephone. “But most of the time it comes down to the patient’s feelings, and what it’s going to cost them out of their own pocket.”

Using Avastin

The controversy over the use of Lucentis in eye patients dates to 2005 when Philip Rosenfeld, a professor at the Bascom Palmer Eye Institute in Miami, began using Avastin, a Roche cancer drug, in patients with age-related macular degeneration, a disease that develops when blood vessels behind the eye leak into the retina. Avastin works similarly to Lucentis by blocking a protein critical to the formation of blood vessels, and studies showed they work equally well.

While Lucentis was in development at the time, Rosenfeld said he didn’t wait for its approval to help his patients. Instead, he turned to Avastin. While Avastin remains unapproved for eye patients, doctors looking to save their patients money now use it regularly in smaller doses than is used in cancer patients.

Ophthalmologists interviewed this week have unanimously said insurance policies and out-of-pocket costs drive drug choice.

Approved Drugs

While Lucentis and Regeneron Pharmaceuticals Inc.’s Eylea are more expensive than Avastin, they are approved by the U.S. Food and Drug Administration. Patients who have Medicare plus supplemental insurance that completely covers the cost typically chose the FDA approved drugs, said Robert Braunstein, an eye doctor in Morristown, New Jersey.

Braunstein made $408,950 from Medicare in 2012, according to the data, placing him in the middle of the ophthalmologist pack. He said there’s not much profit in doing injections, and the price difference doesn’t lead doctors to use one drug over the others.

On the other hand, doctors agreed that patients who have to pay for a portion of the drug’s price elect to receive Avastin, which costs less than $50 total.

Doctors get Avastin from compounding pharmacies, which order vials of the drug made for cancer patients and cut it into smaller portions that can be used in the eye. The drug isn’t approved by the FDA for that use, though there are no prohibitions against it. The compounding process raises the risk of infection. Sporadic recalls of Avastin occur because of eye infections among patients getting it.