Aduhelm and Medicare Coverage in 2023

Aduhelm is an FDA-approved drug for Alzheimer’s disease. When it was first announced in 2021, it offered a potential future of monoclonal antibody treatments for those with Alzheimer’s. But its initial $56,000 price tag worried people about what Medicare approval of this treatment would mean for Medicare costs.

A lot has happened since that announcement. In this post, we will explore the continuing story of Aduhelm and the current state of Medicare coverage.  

Please note: This blog is for educational purposes only and should not be substituted for personalized medical advice.

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?

When Aduhelm first came out, it cost $56,000 per year.

Fortunately, Biogen, the manufacturer of Aduhelm, announced late last year that they would reduce the cost of Aduhelm by 50%, or $28,200 per year, which is still very expensive. That price tag includes 12 IV treatments over the course of one 12-month period. 

Aduhelm and Medicare costs

In 2021, CMS announced a significant increase to the 2022 Medicare Part B premiums. This increase, they explained, was to offset the high cost Aduhelm would put on the Medicare system if approved for general use.

As of now, it is not approved for general use and Medicare has lowered Part B premiums in 2023 due to this decision.

Does Medicare cover Aduhelm?

Currently, Medicare only covers Aduhelm for those enrolled in a qualifying clinical trial. The decision concerning Aduhelm coverage was announced in April 2022.  

The announcement states that, while FDA approval has been given, too many questions still exist about the efficacy of this high-cost treatment. That is why they are covering costs for those in CMS-approved studies to further research the long-term efficacy of Aduhelm, which will determine the future of Medicare coverage.

You can read the entire press release here.

What are the Medicare coverage criteria for Aduhelm?

The Medicare coverage criteria for Aduhelm, and other drugs like it that may appear in the future, are very strict. First, the drug must be FDA-approved. Aduhelm was approved in 2021 and is currently the only monoclonal antibody treatment for Alzheimer’s.  

The main rule about coverage, though, is that you must be in a CMS-approved clinical research study. This means you must meet the specific needs of the study before Medicare will consider approval. Click here to read more about Medicare coverage criteria.

If I qualify for Aduhelm, what would my costs be?

If Medicare does opt to cover your participation in an Aduhelm trial, it would be covered under Medicare Part B. That means Medicare would cover 80% of the drug cost.

For those with a Medicare Supplement, your plan would cover the 20% coinsurance in full. Your out-of-pocket cost for Aduhelm would be $0 after you meet your Part B deductible, which is $226 in 2023.

For those with Medicare Advantage plans, the out-of-pocket cost for Aduhelm would depend on your specific plan.  

Conclusion

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 appears to be a potential aid for those with progressing symptoms. However, questions about costs, Medicare coverage, and long-term effectiveness leave many wondering if the drug is worth it. For now, information is still being collected and the future of Aduhelm coverage is still to be determined. You should communicate with your insurance carrier to know whether your plan covers this drug.

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