Trends in AntiVascular Endothelial Growth Factor Injections Among Medicare Part B Beneficiaries in 2013–2021 and the Step Therapy Era

<b>Purpose:</b> To analyze anti-vascular endothelial growth factor (anti-VEGF) injection trends for Medicare Part B beneficiaries during the period 2013-2021, as well as before and after step therapy implementation. <b>Methods:</b> This study examined ophthalmologists administering intravitreal anti-VEGF injections to Medicare Part B beneficiaries from January 1, 2013 through December 31, 2021. Data were gathered from the Medicare Physician & Other Practitioners - by Provider and Service database and identified using Current Procedural Terminology codes specific to bevacizumab, ranibizumab, and aflibercept. Statistical analyses were conducted using R. <b>Results:</b> Among 26 602 816 total injections performed from 2013 to 2021, relative usage of aflibercept increased by 158.3%, while relative usage decreased by 27.5% for ranibizumab and 49.6% for bevacizumab. After step therapy implementation, relative usage of aflibercept increased by 32.0%, while there was a decrease in relative usage of bevacizumab by 33.2% and ranibizumab by 4.3%. When ophthalmologists were grouped according injection volume for each medication in 2021 (ie, top 10%, or high-volume injectors), the proportion of aflibercept injections performed by high-volume aflibercept injectors (32.3% of total nationwide aflibercept injections) was lower than the proportion of ranibizumab injections performed by high-volume ranibizumab injectors (43.2% of total nationwide ranibizumab injections) and the proportion of bevacizumab injections performed by high-volume bevacizumab injectors (41.2% of total nationwide bevacizumab injections). Ranibizumab was less frequently used than aflibercept or bevacizumab. Ophthalmologists in the study time period primarily treated patients with aflibercept and bevacizumab or aflibercept and ranibizumab, with many fewer using primarily ranibizumab and bevacizumab. <b>Conclusions:</b> Aflibercept usage has continued to rise, matched by a decline in bevacizumab usage and a modest decrease in ranibizumab usage. Step therapy has not significantly increased bevacizumab usage on an aggregate level.