Cost-neutral adoption of anti-VEGF therapies in neovascular age-related macular degeneration

OBJECTIVE: In therapeutic classes characterized by outcome equivalence, the decision problem shifts from incremental cost-effectiveness to cost-neutral pricing. This study formalizes a break-even pricing framework translating real-world utilization and costs into cost-neutral price thresholds, using anti-VEGF therapies for neovascular age-related macular degeneration (nAMD) as a case study. METHODS: A cost-minimization framework was applied from a public payer perspective in a single-payer system (Cyprus). Five anti-VEGF agents were evaluated over three years with 3.5% discounting. Injection frequencies were derived as weighted averages of treat-and-extend and pro re nata regimens from Phase 3/4 trials, with year 3 extrapolated from year 2. Break-even prices were defined as unit prices yielding equal discounted per-patient costs versus comparators. First-line thresholds used bevacizumab; second-line thresholds used a utilization-weighted comparator. Sensitivity analyses were conducted. RESULTS: Bevacizumab defined the lowest-cost benchmark (€4,130). Cost-neutral first-line use of newer agents required price reductions of 84-98%. Under second-line utilization, several agents fell below break-even thresholds at list prices. Key drivers were acquisition price, injection frequency, and monitoring costs. CONCLUSION: Break-even pricing generates explicit cost-neutral thresholds under outcome equivalence. While jurisdiction-specific, the framework is transferable and supports consistent pricing decisions in single-payer systems.