Approximately 6.7 million Americans aged 65 or older are living with Alzheimer’s disease, and many could benefit from treatments that could slow its progression. However, the coverage provided by Medicare for these treatments and medications is a complicated and evolving matter. In this article, we delve into the intricacies of Medicare coverage for Alzheimer’s disease, exploring both the existing coverage options and the recent developments regarding new treatments.
Medicare and Alzheimer’s Drugs:
While there are no drugs or treatments that can cure Alzheimer’s disease, Medicare Part D prescription drug plans offer coverage for five medications that address cognitive symptoms. Three of these medications, Aricept, Exelon, and Razadyne, are cholinesterase inhibitors that help manage memory, language, judgment, and other cognitive processes. Aricept is approved for all stages of Alzheimer’s, while Exelon and Razadyne are approved for mild to moderate disease. Additionally, Namenda and Namzaric, both prescribed to improve memory, language, and daily tasks, are approved for moderate to severe Alzheimer’s.
Coverage of Adulhelm and Leqembi:
Adulhelm and Leqembi, two new treatments garnering significant attention for their potential to slow the progression of Alzheimer’s, have been the subject of ongoing discussions regarding Medicare coverage. Adulhelm and Leqembi are intravenous infusion therapies designed to target amyloid plaques associated with early Alzheimer’s.
In June 2021, Adulhelm received accelerated approval from the FDA, leading to Medicare considering coverage options. In April 2022, the Centers for Medicare and Medicaid Services (CMS) announced that Medicare would cover Adulhelm and similar treatments only for beneficiaries with Medicare Part B who are enrolled in an approved clinical trial. This decision drew criticism from advocacy groups like the Alzheimer’s Association, who argued that these treatments should be accessible to all patients with early Alzheimer’s, rather than just those in clinical trials.
It is worth noting that the administration of Adulhelm can be challenging to find, as some health systems have expressed concerns about safety and effectiveness and chosen not to administer it.
Medicare’s coverage of Adulhelm involves the beneficiary paying 20% of the cost, which amounts to approximately $5,640 per year. However, the out-of-pocket limit for individuals with Medicare Advantage plans is around $5,100. Additionally, due to projected increased spending for Adulhelm coverage, CMS raised the monthly Part B premium in November 2022. The coverage and cost considerations for Leqembi are still pending FDA approval and subsequent decisions by CMS.
The Debate over Coverage:
Critics and advocates have expressed varying opinions on the coverage approach for Alzheimer’s treatments. Some believe that the requirement of a special registry for physicians and patients could create barriers to access, particularly for those in rural or underserved areas. Advocacy groups argue that Medicare coverage should be available regardless of enrollment in a registry, similar to the coverage provided for other FDA-approved drugs.
Future Developments:
Medicare’s decisions regarding coverage for Alzheimer’s treatments are anticipated to evolve further. The FDA is expected to decide on granting full approval to Leqembi for all individuals with mild cognitive impairment or mild dementia with amyloid plaques by July 6. CMS will subsequently determine how Medicare will cover Leqembi and consider potential changes to coverage rules for Adulhelm.
Conclusion:
The complex landscape of Medicare coverage for Alzheimer’s treatments presents challenges and uncertainties for individuals living with the disease. While Medicare currently covers certain medications for cognitive symptoms, the coverage of newer treatments such as Adulhelm and Leqembi has been met with ongoing debate. As Medicare continues to evaluate coverage options, it is crucial to balance accessibility with cost considerations to ensure that those affected by Alzheimer’s can benefit from advancements in treatment while minimizing financial burdens.
