Innovation Without Access: Why Ophthalmology’s Breakthrough Therapies Need Stronger Support

Ophthalmology is undergoing a wave of therapeutic innovation, one that could significantly change the trajectory of care for millions of people. Several new treatments have recently been approved across a range of conditions, from presbyopia to glaucoma. A robust pipeline of long-acting biologics, gene therapies, novel topicals, and surgical innovations, spanning everything from dry eye to inherited ocular conditions, are also moving through late-stage development. But while innovation is accelerating, the infrastructure that supports patient access hasn’t necessarily kept pace. 

Of the more than 20 million people in the U.S. living with these sight-threatening conditions, ~1 in 3 may be receiving less-than-optimal care due to insurance-related delays, step edits, and affordability barriers. According to Spherix Global Insights’ latest RealTime Dynamix survey, specialists report that payer restrictions are now a routine factor in prescribing decisions, and that administrative burden remains high, even in well-resourced practices. 

In this environment, patient services must play a more strategic role. It’s no longer just about operational support; it’s about actively enabling access, easing the burden on providers, and ensuring patients can start and stay on the therapies they need. 

How Administrative Burden Disrupts Care Delivery 

Many of today’s ophthalmology practices are strained by fragmented systems and rising administrative demands. Providers are managing complex patient populations, often older adults with multiple chronic conditions who require frequent follow-ups and ongoing care. 

For office staff, each visit must be coordinated around increasingly complex coverage requirements. Providers face layers of payer rules, often compounded by automated utilization tools that trigger denials based on incomplete data or rigid logic. Step therapy protocols introduce further delays, forcing providers to consider lower-cost alternatives before accessing their treatment of choice. Staff regularly spend hours chasing documentation and resolving issues. And because ophthalmology is often a buy-and-bill environment, practices face financial risk if coverage isn’t confirmed upfront. 

These access barriers have real clinical impact. When benefit verification or prior authorization is delayed, treatment plans can be disrupted, especially if coverage isn’t confirmed in time for a scheduled injection. Patients are left waiting, and for those already managing the demands of monthly therapy, that added uncertainty can make adherence even harder to sustain. 

In this climate, introducing a newly approved therapy doesn’t just mean educating the field. It means navigating a thicket of prior authorization requirements, payer variation, and reimbursement unknowns. Even when a therapy shows clear clinical benefit, practices may hesitate to prescribe it until they have confidence in the reimbursement pathway. Without strong patient services in place to remove friction and support adoption, even the most promising therapies can struggle to gain traction. 

What Impactful Patient Services Look Like in Ophthalmology 

Effectively supporting access in ophthalmology requires programs tailored to the space’s unique demands. The strongest models go beyond basic logistics to reduce friction, support provider workflows, and help patients start and stay on therapy. A few capabilities consistently make the difference: 

Frictionless onboarding: Practices vary widely in workflow and digital maturity. Supporting a range of enrollment methods, from fax to eRx to self-service portals, makes it easier for providers to start patients on therapy without disrupting clinical flow. 

Reliable benefit verification across both medical and pharmacy benefit: Coverage clarity is foundational. Programs should offer high-accuracy benefit verification for both medical and pharmacy claims, with clear documentation that helps providers understand acquisition options and PA requirements before treatment is scheduled. 

Affordability support built for Medicare-heavy populations: Many ophthalmology patients face high out-of-pocket costs or don’t know they qualify for assistance. Programs should include tools to identify Low-Income Subsidy (LIS) eligibility, perform real-time income checks, and educate patients early on how to minimize financial barriers. 

Strategic prior authorization support: As payers place greater emphasis on biosimilars, prior authorization requirements may become more complex, particularly when providers are seeking access to branded therapies. Support teams need to be able to collect clinical documentation, submit on behalf of the provider when appropriate, and follow through to resolution. 

Visibility across the care journey: When multiple parties- patients, providers, pharmacies, field teams- are involved, status visibility becomes critical. Programs should offer real-time tracking tools that allow teams to resolve issues quickly and keep therapy moving. 

Specialized staffing: Many patients in ophthalmology have ongoing, complex health needs, and often live with low vision that affects their daily independence. Tasks like navigating portals, managing appointments, or traveling to and from care often require support from a caregiver. That makes live, human support especially important. Staff must be experienced, empathetic, and able to manage both reimbursement complexities and the personal side of care- often through direct outreach, one-on-one guidance, and coordination with caregivers when needed. 

What It Will Take to Support the Next Wave of Innovation 

These innovations in ophthalmology promise long-term benefit and reduced treatment burden, but they may also come with higher payer scrutiny, more complex documentation needs, and an even greater need for long-term coordination. Supporting them will require thoughtful program design, tailored reimbursement strategies, and seamless coordination between patients, providers, and pharmacies. 

As these new therapies enter the market, manufacturers have an opportunity to reassess how patient support programs function, and where they may be falling short. Without the right support in place, even the most innovative treatments may struggle to reach the patients they’re designed to help. To learn how CareMetx can help you strengthen your patient services strategy, contact us here.