Will Medicare Pay for Alzheimer’s Drugs? The Answers Are Complex and Vary

Medicare and Alzheimer’s disease drugs

There is no drug or treatment that will cure Alzheimer’s disease. However, if he has a Medicare Part D prescription drug plan, he can get Medicare coverage for five drugs that treat dementia symptoms.

three of which are Aricept, Excelon Lazadaine is a cholinesterase inhibitor that treats symptoms related to memory, language, judgment, and other thought processes. Aricept is FDA-approved to treat all stages of Alzheimer’s disease. Exelon and Razadyne are approved for mild to moderate disease.

Namenda and Namzaric are approved for moderate to severe Alzheimer’s disease. Namenda is a glutamate modulator and Namzaric is a combination cholinesterase inhibitor and glutamate modulator. Both are formulated to improve memory, language, and the ability to perform simple tasks.

Does Medicare Cover Adulhelm and Rekumbi

New types of Alzheimer’s disease treatments are gaining a lot of attention because they may be able to slow the progression of the disease. Adulhelm and Rekumbi are expensive intravenous (IV) infusions of anti-amyloid antibodies for patients with early Alzheimer’s disease.

After a tortuous regulatory process over the past few years, Medicare is applying Adulhelm to certain people with early-stage Alzheimer’s disease.

In June 2021, “FDA granted accelerated approval of Adulhelm, contrary to advisory committee advice. CMS [The Centers for Medicare and Medicaid Services, which runs Medicare] And then I said, ‘Well, let’s figure out what to do about it,'” said Tricia Newman, senior vice president of the KFF, a health policy research and news agency, and executive director of the Medicare Policy Program. says.

Medicare usually covers what the FDA approves.

In April 2022, CMS decided that Medicare would cover a treatment similar to Adulhelm (cost: $28,200 a year, down from the original price of $56,000). that’s all For Medicare Part B beneficiaries enrolled in a clinical trial approved by a government agency or the National Institutes of Health.

“We are very disappointed with the way CMS has chosen to cover or not cover FDA-approved Alzheimer’s drugs through Medicare,” said Robert Egge, chief public policy officer for the Alzheimer’s Association. says. “These treatments have the potential to make a big difference in the lives of people with early Alzheimer’s disease,” he added.

The Alzheimer’s Association said in a statement after the CMS decision in April 2022 that “only a privileged few with access to clinical trials can receive treatment with this approach.”

Finding a health care provider to administer Adalhelm can be difficult. Some health systems have Cleveland Clinic, General Brigham Mass The Commonwealth Foundation, a medical research group, said the city of Mount Sinai in New York City said it would not administer it due to concerns about its safety and effectiveness.

If Medicare covers Adulhelm, 80% of the cost will be paid. Beneficiaries pay the rest, approximately $5,640 per year.Average out-of-pocket limit for people with the following diseases Medicare Advantage Private health insurance plans that replace traditional Medicare are just over $5,100.

In November 2022, CMS increased the Part B monthly premium by $21.60 to $170.10 due to an expected increase in Medicare spending on Adulhelm insurance. Part B premiums drop to $164.90 in 2023.

A similar treatment to slow Alzheimer’s disease, Rekumbi, received “accelerated approval” from the FDA in January 2023. Veterans Health Administration started covering it Select veterans aged 65 and older will be eligible in March 2023.

In early June, CMS announced that if the FDA grants conventional approval to a drug that slows Alzheimer’s disease, Medicare will cover the cost of eligible recipients who include physicians in the special registry.

Some critics believe registration is cumbersome for physicians and patients and may exclude patients in rural and underserved areas.

Diane Omdahl, Author Medicare for you The registry, which is also CEO of 65, Inc., a Medicare advisory firm, said the registry “will definitely be a roadblock to making Alzheimer’s drugs available to people.”

The Alzheimer’s Association calls registration an “unnecessary barrier” to insurance coverage.

“You should be eligible for Medicare coverage whether you’re enrolled or not,” says Egge. “This is always true of all other FDA-approved drugs, without exception.”

The FDA plans to decide by July 6 whether to grant full approval of Rekumbi for all people with mild cognitive impairment or mild dementia with amyloid plaques.

CMS will then have to decide if and how Medicare will cover it, and whether to change Aduhelm’s coverage rules.

Nearly 9 in 10 voters support requiring Medicare to pay for FDA-approved drugs that slow the progression of Alzheimer’s disease. recent polls Found from Lake Research Partners and Public Opinion Strategies.

In the coming months, Medicare will also announce whether it will target Lilly’s donamab, another drug that has shown clinical benefit in early Alzheimer’s patients. A clinical trial showed that the drug slowed the progression of Alzheimer’s disease by 35% compared to a placebo.

Will Medicare eventually cover all Alzheimer’s patients who qualify for these drugs? ,” says Egge.

The KFF estimates that if 5% of Alzheimer’s patients (about 335,000 people) received Rekembi at its list price of $26,500, it could increase Medicare Part B spending by $8.9 billion annually. Part B premiums are also likely to go up, Omdahl said.

But the Alzheimer’s Association believes that only about 100,000 people will take Adulhelm and Rekumbi in a few years.

Rekembi and Adulhelm’s annual costs approach the median income of a Medicare subscriber of $30,000.