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Does Medicare Cover Leqembi?

Summary: Leqembi was approved by the FDA to treat the early stages of Alzheimer’s disease. It was granted full approval on July 6, 2023. After much-anticipated debate, Medicare is providing coverage for Leqembi through Medicare Part B. Find out about Leqembi and how to get Medicare coverage for the drug below. Estimated Read Time: 4 mins

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Table of Contents:

  1. What is Leqembi?
  2. How Does Leqembi Work?
  3. How to Receive Coverage for Leqembi Through Medicare
  4. Who is Eligible for Medicare Coverage of Leqembi?
  5. Will the Inflation Reduction Act Help with Leqembi Costs on Medicare?

In July 2023, the U.S. Food and Drug Administration approved the Alzheimer’s drug Leqembi. Shortly after the FDA’s approval, the Centers for Medicare and Medicaid Services (CMS) stated that Medicare will cover Leqembi under Original Medicare Part B.

However, Medicare will not cover the entire cost of Leqembi, and the drug may not even be appropriate or accessible for every Alzheimer’s patient. We will share everything you need to know about Leqembi so you can decide if it’s right for you or your loved one.

What is Leqembi?

Leqembi (pronounced Le-Kem-Bee) is the brand name for the drug lecanemab. It’s made by the pharmaceutical companies Eisai and Biogen, and it is the first in a new class of drugs that appears to slow the progression of Alzheimer’s disease.

Leqembi has been shown to improve cognition and memory in clinical trials, so full FDA approval has been granted for the drug to go on the market for physicians to prescribe. Leqembi can treat mild cognitive impairment and mild Alzheimer’s disease dementia.

How Does Leqembi Work?

Leqembi works by targeting a protein, beta-amyloid plaque, that has been shown to accumulate in the brains of those with Alzheimer’s disease.

If prescribed, the drug is administered intravenously at the patient’s doctor’s office. The patient must get infusions of Leqembi every two weeks for 18 months to slow the progression of Alzheimer’s by about 6 months.

Side effects of Leqembi may include brain swelling or bleeding and infusion-related reactions such as headaches. Other side effects may include nausea, vomiting, diarrhea, occasional changes in blood pressure, and flu-like symptoms.

How to Receive Coverage for Leqembi Through Medicare

Leqembi is covered by Medicare Part B. Prescription drugs are typically covered by separate Medicare Part D plans, but because Leqembi is a physician-administered drug through I.V. treatments, Medicare Part B will cover it.To receive coverage for Leqembi there are a few steps you must take.

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Enroll in Medicare Part B

The first step to receiving Medicare coverage for Leqembi is to enroll in Medicare Part B coverage. Although Leqembi is a prescribed medication, it is covered by Medicare Part B due to its administration.

Obtain a Prescription for Leqembi

Before Medicare will cover Leqembi, you will need to be prescribed the medication for a covered health condition. Once prescribed, Medicare will need to approve your injection before they will cover the drug.

Receive Leqembi Administered by a Licensed Medicare Professional

Once you have been approved for Leqembi by your healthcare provider, it is time to receive your injection administered by a medical professional.

Leqembi costs about $26,500 for a year’s worth of treatment. Medicare Part B will cover 80% of the cost after you meet your yearly deductible. That would leave you with 20% in out-of-pocket expenses for Leqembi (around $5300 after the deductible) unless you enroll in a Medicare Supplement (Medigap) plan.

Most Medigap plans would cover the other 20% of costs. However, you would have to pay a monthly premium for a Medicare Supplement plan and the premium rate would vary depending on several factors. These factors include:

  • The Medigap insurance company
  • Your age
  • Your gender
  • Your location (state and ZIP code)
  • Your tobacco use

It’s important to do your research comparing the different Medicare Supplement plans and the benefits they offer. You would also have to research Medigap carriers in your area and their premium rates. Talking to a licensed agent can help point you in the right direction so you can learn what kind of Medicare coverage would be best for covering the costs of Leqembi.

It’s also important to note that CMS requires Medicare beneficiaries to enroll in a patient registry through their website so that they can collect more data on Leqembi. You must register in order to receive any coverage of Leqembi through Medicare.

Who is Eligible for Medicare Coverage of Leqembi?

CMS has stated that it will only cover Leqembi for Medicare patients who meet all of the following criteria. These requirements include:

  • Being diagnosed with mild cognitive impairment or mild dementia
  • Having documented evidence of beta-amyloid plaque on the brain, which can be commonly found in those with Alzheimer’s
  • Having a doctor who participates in a qualifying registry and who maintains proper follow-up care alongside an appropriate clinical team

To document evidence of beta-amyloid plaque, patients will typically need to get additional testing done to see if they have it in their brain. These tests include either a lumbar puncture (also called a spinal tap) or a PET scan.

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However, it is important to ensure Medicare will cover any brain scans or other tests and services needed to get Leqembi treatments.

Those with more advanced forms of Alzheimer’s disease or more severe degenerative cognitive symptoms likely will not qualify for Leqembi treatment or coverage through Medicare.

Will the Inflation Reduction Act Help with Leqembi Costs on Medicare?

President Joe Biden signed the Inflation Reduction Act into law in 2022. It has a provision to cap out-of-pocket drug expenses at $2000 per year for Medicare beneficiaries by 2025. Unfortunately, this provision won’t apply to Leqembi.

This is because the IRA only affects drug costs through prescriptions covered by Medicare Part D plans. Since Leqembi is covered under Medicare Part B as a doctor’s service, it won’t qualify for the IRA out-of-pocket cost cap.

How to Get Help with Medicare Coverage for Leqembi

Whether you’re a new Medicare beneficiary or you’ve been on Medicare for a few years, it can be hard to find the right information. This is especially true for a brand-new treatment like Leqembi.

At MedicareFAQ, we have licensed insurance agents who are happy to answer any Medicare questions you may have and help you find the right coverage that fits your healthcare needs and budget.

Just call the number above to speak to a trusted agent. We understand you’re busy, so if you don’t have the time to call now, you can fill out our online rate form to compare Medicare plans and prices in your area.

Sources

MedicareFAQ is dedicated to providing you with authentic and trustworthy Medicare information. We have strict sourcing guidelines and work diligently to serve our readers with accurate and up-to-date content.

Kayla Hopkins

Kayla Hopkins

Content Editor
Kayla Hopkins is an accomplished writer and Medicare guru serving as the Editor of MedicareFAQ.com. Upon completing her Communications degree from Ohio University, Kayla dedicated her time to understanding the ever-evolving landscape of healthcare. With her extensive background as a Licensed Medicare Insurance Agent, she brings a wealth of knowledge and expertise to her writing.
Ashlee Zareczny

Ashlee Zareczny

Compliance Manager
Ashlee Zareczny is the Compliance Manager for MedicareFAQ. As a licensed Medicare agent in all 50 states, she is dedicated to educating those eligible for Medicare by providing the necessary resources and tools. Additionally, Ashlee trains new and tenured Medicare agents on CMS compliance guidelines. Ashlee is a Medicare expert who specializes in Medicare Supplement, Medicare Advantage, and Medicare Part D education.

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