Will Health Insurance Cover New Alzheimer’s Drug, Aduhelm?
Lauren Lewthwaite 15-06-2022

Medicare Coverage of Aduhelm

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Alzheimer’s disease is a brain disorder that erodes memory and thinking skills over time, leading to significant cognitive decline. Almost 6 million people in the US have Alzheimer’s disease today, and that number is expected to rise to 14 million by 2060. It’s no wonder that a fight for a cure is underway and why drug therapies, like Aduhelm, are so high in demand. 

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What is Aduhelm?

Aduhelm is a drug to help treat Alzheimer’s disease for those with mild symptoms. While there is no cure for Alzheimer’s that exists today, Aduhelm is designed to target amyloid-beta plaques in the brain and rid your body of them, in order to potentially slow cognitive decline. 

Aduhelm is administered monthly and can be taken for years as it’s not curative. The drug is FDA approved, but there are some questions about its efficacy and safety of the drug. 

Will Health Insurance Cover Aduhelm?

Medicare recently announced that it would cover Aduhelm, despite the high cost of the drug. However, the decision is conditional; only patients registered in a clinical trial are approved to receive the drug under Medicare coverage. This decision is designed to give patients coverage while gathering data on the efficacy of the drug. 

Medicare will cover participants in any trial that’s approved by the FDA or the National Institutes of Health (NIH) in a range of locations, not just hospitals. As well, those with other neurological conditions like Down Syndrome can be included in the trials. Medicare will require the trials to be racially and ethnically diverse, to reflect the higher prevalence of Alzheimer’s disease among Black and Hispanic communities. 

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The Cost of Aduhelm Under Medicare

For those eligible for coverage, there are valid concerns regarding the high cost of the drug that may need to be taken for years. Initially, Aduhelm was priced at $56,000 per year but that price dropped to a slightly more affordable $28,200 amid slow sales.

Medicare will include Aduhelm under Part B, which covers outpatient drugs. They will cover 80% of the cost of the drug, while the policy-holder will be responsible for the other 20%. If they have supplemental insurance that covers Aduhelm, this can be used towards that 20%.

So, what does that look like in terms of numbers? The average person under Medicare could pay $5,640 out of pocket per year (assuming no supplemental coverage). However, this may cause Part B premiums to increase. 

Medicare Advantage plans have out-of-pocket limits for Part B drugs, but those limits are typically just a few hundred short of the average cost of Aduhelm, meaning beneficiaries are still responsible for most of the out-of-pocket fees.

Health Insurance and Aduhelm

Medicare’s decision is a controversial decision, to say the least, and it’s not yet clear if many (or any) other insurers will follow suit. Many of the large insurers don’t deem the drug medically necessary, according to one survey, and are uncertain about its safety and benefits. 

Further to this, many health systems and hospitals have already made the decision not to prescribe Aduhelm, which may make it even harder for patients to get access to the drug.

The Bottom Line: Does Health Insurance Cover Aduhelm?

Medicare’s controversial decision to conditionally cover Aduhelm means that millions of people suffering from Alzheimer’s disease may have access to the drug. However, the access comes at a steep price that might not be feasible for all. 

Time will tell whether more insurers follow suit, especially based on the pending results of more clinical trials on the safety and efficacy of the drug. 

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Lauren LewthwaiteLauren Lewthwaite has been freelance writing for almost five years writing content that ranges from health to insurance and everything in between. Lauren is also a trained translator in French and English and is a dog-mom to an adorable Australian Shepherd.