Aduhelm and Medicare Coverage
For many, the FDA approval of Aduhelm — the first drug approved for Alzheimer’s disease in over 18 years — offers a hope for treatment.
But with a $56,000 price tag, that hope seems far fetched for many suffering with diminishing cognition. Today we’re going to look at this polarizing medication and find out what it is and if Medicare covers it.
UPDATE: December 20, 2021: Biogen announced today they will reduce the cost of their $56,000 Alzheimer's treatment by 50% – or $28,200 (Yahoo Finance).
What is Aduhelm/aducanumab?
Aduhelm (the name brand for aducanumab), is an innovate medicine that is given intravenously to help treat and slow down the progression of Alzheimer’s disease.
Aduhelm is the first drug of its kind. It works by attacking beta-amyloid plaques, which are clumps of a toxic protein that are believed to destroy neurons in the brain. Many in the field believe the beta-amyloid plaques are what cause Alzheimer’s disease, so the hope is that Aduhelm can slow down or delay the onset of cognitive decline.
It is important to remember that Aduhelm is not a cure for Alzheimer’s disease and it does not reverse the progression of the disease. It is designed to slow progression in those with mild or medium plaque buildup.
How much does Aduhelm cost?
Aduhelm costs $56,000 per year.
That price tag includes 12 IV treatments over the course of one 12-month period. It’s a hefty price tag for a treatment that still is being debated. The results of the medication are inconclusive as to its efficacy at this point, leaving many wondering if the cost outweighs any potential benefits.
Does Medicare cover Aduhelm?
As of November 2021, Medicare is reviewing their decision on whether or not they will cover Aduhelm. This decision is likely to be announced in early 2022. As of now, many insurance carriers are saying they will not cover the costs of Aduhelm. Most notably is the VA, who have announced that they will not be offering coverage of Aduhelm.
Many insurance experts are concerned that if Medicare does choose to cover Aduhelm, costs will increase for all Medicare users, making it difficult for many seniors to afford their premiums.
As anything covered by Medicare must also be covered by supplement and Medicare Advantage plans, the ripple effect of cost increases due to Aduhelm is a valid concern, one we can already see the beginnings of in 2022 Medicare coverage.
Part of the reason Medicare Part B premiums were raised this year was in anticipation for expected costs for Aduhelm if it is approved, although the main reason for the premium increase was due to COVID-19.
If Medicare covers Aduhelm, what would my costs be?
If Medicare covers Aduhelm, it would be covered under Medicare Part B. Part B would cover 80% of the drug cost, or $44,800 for a year’s worth of treatment. This would leave 20% of the cost to the individual. That’s $11,200 that you would have to pay out of pocket.
For those with a Medicare Supplement, your plan would cover that 20% coinsurance in full. Your out-of-pocket cost for Aduhelm would be $0 after you meet your Part B deductible, which is $233 in 2022.
For those with Medicare Advantage plans, the out-of-pocket cost for Aduhelm would depend on your specific plan. But, for many, the cost of Aduhelm with a Medicare Advantage plan would likely be much higher than for those with a Medicare Supplement.
Alzheimer’s disease is a serious health concern for many Americans. If you have any questions about Alzheimer’s or any other cognitive concern, we recommend you speak with your primary care physician. If you would like to learn more about Alzheimer’s, please visit www.alz.org.
Aduhelm may offer an opportunity to slow the progression of Alzheimer’s disease. However, it also leaves many with questions about costs, coverage and what this drug means for the future of Medicare as a whole.
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