Will health insurance cover new Alzheimer’s drug, Aduhelm?

What is Aduhelm?

Aduhelm is a new drug used to treat Alzheimer's disease. In June, the U.S. Food and Drug Administration gave the medicine an accelerated approval so that it can be used to treat patients with dementia.

The drug -- which goes by the generic name aducanumab -- works to rid the brain of beta-amyloid, a protein that prevents neurons from functioning properly. Many scientists believe a buildup of beta-amyloid leads to Alzheimer's disease. 

The Alzheimer’s Association called Aduhelm “a marginal but potentially meaningful slowing of decline for this subpopulation of individuals with Alzheimer’s disease, a terminal disease with no survivors.” The advocacy group said it’s “committed to working with CMS and the private payer community to expedite access for the appropriate population, which has such significant need.”

While some consider Aduhelm to be a breakthrough in Alzheimer's treatment, it’s not without controversy. Critics say there isn’t enough proof that simply removing beta-amyloid clumps from the brain actually will improve brain functioning. 

The watchdog group Public Citizen called the FDA decision to accelerate approval "reckless." And an influential panel of experts -- the Institute of Clinical and Economic Review -- recently agreed in a 15-0 vote that there’s no evidence that Aduhelm offers a net health benefit to patients.

The accelerated approval was so controversial that three members of an FDA panel that debated whether to approve Aduhelm resigned in protest over the final decision.

The cost of Alzheimer’s care can be expensive, and this new drug is no exception. Aduhelm is estimated to cost $41,000 for the first year and $56,000 for subsequent years.

Will Medicare cover Aduhelm?

The U.S. Centers for Medicare and Medicaid Services announced that it will review Aduhelm before deciding whether to standardize coverage of the drug throughout the U.S.

The review process will use a mix of data analysis and public hearings to determine whether the drug is a "reasonable and necessary" treatment. The process should take around six months, with a final decision within nine months. If CMS decides that the drug meets that standard, Medicare is required by law to pay for it.

The fact that Aduhelm is undergoing this review process isn’t unusual, says Cheryl Fish-Parcham, director of access initiatives at Families USA, a national, nonpartisan consumer health care advocacy organization.

“Because Aduhelm is a new drug, Medicare and some other insurers are in the process of determining their guidelines about when it will and won’t be covered,” she says.

For now, contractors that administer Medicare for the government in 12 regions are making their own decisions about Aduhelm coverage in their regions, the Wall Street Journal reports.

Critics of the FDA decision to approve Aduhelm say that the high cost of the Alzheimer's disease drug could result in the federal government spending billions of dollars for a medicine that they contend remains unproven.

If Medicare eventually decides to cover Aduhelm, it will be handled a bit differently than some other prescriptions, Fish-Parcham says.

“To the extent that Medicare covers the drug, Medicare will eventually cover the drug under Part B, the part of Medicare that pays for outpatient care,” she says.

Most drugs that Medicare covers fall under Part D, the program’s prescription drug benefits for beneficiaries with Original Medicare.

Will private health insurance cover Aduhelm?

Questions remain about whether or not private insurance companies will cover Aduhelm. Some health insurers have said they won't cover the medication. They include Blue Cross and Blue Shield of North Carolina, which has cited concerns about both the drug's effectiveness and risks associated with the medicine, including brain bleeding and swelling.

Blue Cross Blue Shield insurers in Michigan and Pennsylvania also have said they will not cover Aduhelm.

The two largest providers of Medicare Advantage plans -- UnitedHealth Group and Humana -- say they are waiting for guidance from the Centers for Medicare and Medicaid Services before deciding whether to cover Aduhelm.

In addition, three major hospitals -- Cleveland Clinic, Mount Sinai Health System in New York and Providence in Renton, Washington -- have said they won’t administer Aduhelm.

So, for now, Alzheimer’s insurance coverage of Aduhelm remains up in the air. Make sure you're clear about your health plan providers stance on Aduhelm before pursuing treatment with the drug.

“Follow the news and keep in touch with medical professionals and disease associations to learn when it becomes available,” Fish-Parcham says.

What to do if your health insurance doesn’t cover a prescription drug

Talk to your doctor if your health insurer won’t cover the cost of a prescription drug.

“If there is not another drug or medical procedure that will work for you, ask the doctor to help you request an exception from your health plan,” Fish-Parcham says.

You can appeal the decision if the plan won’t grant you an exception. Appeals can be filed with your health insurer or to another entity that is independent of the health plan.

“This involves submitting medical evidence about why you need a specific drug, and why the drugs that the plan normally covers will not work for you,” Fish-Parcham says.

In some states, there are health consumer assistance programs or an ombudsman program that can help with this procedure. If you’re unsure where to turn, contact your state insurance department, Fish-Parcham says.

What Medicare does and doesn’t cover for Alzheimer’s care

Alzheimer's disease care is expensive:

• The average care costs for semi-private rooms in nursing homes is more than $85,000 per year.
• A private room is close to $100,000 a year, which is more than $8,000 per month.
• Assisted living facilities cost an average more than $50,000 annually.
• Home health aides cost an average of $22 per hour.
• Adult daycare services are $70 per day on average.

Medicare offers benefits for Alzheimer’s patients, but the federal health insurance program for those 65 and older doesn't cover all costs.

For example, Medicare covers inpatient hospital care and some doctor fees and medical items for people who have been diagnosed with Alzheimer's disease or other forms of dementia.

Those who enroll in the optional Medicare Part D prescription drug program also will find that it covers some Alzheimer's medications.

Medicare covers up to 100 days of skilled nursing home health care in some situations. However, it doesn’t cover long-term nursing home care -- which can be quite expensive -- for those with Alzheimer's. To get this coverage, you would need to purchase long-term care insurance before being diagnosed with Alzheimer's. Otherwise, the family has to pay for long-term nursing home care, assisted living care and adult day care.

Medicare will pay for hospice care in the home of someone with Alzheimer's. It also will cover such care in a nursing facility or an inpatient hospice facility.

Those who are diagnosed with Alzheimer’s disease or other forms of dementia with cognitive impairment can enroll in a Medicare Special Needs Plan. These Medicare Advantage plans specialize in care and coverage for those who have dementia. According to CMS, these plans "tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve."

If you’re enrolled in an SNP, you typically must get most of your health care from doctors or hospitals in the SNP network.