Designing a Better Managed Care Benefit for Alzheimer's Disease

This episode, titled 'Designing a Better Managed Care Benefit for Alzheimer's Disease,' featured panelists discussing the following critical questions:

Medicare coverage for anti-amyloid therapies has expanded, but coverage does not equal access. What are the current barriers you are facing for diagnosis and treatment, what does the reimbursement and prior authorization landscape look like for community neurologists, and what documentation do practices need to get approvals through efficiently?

Value-based contracting has become a common tool for managing high-cost specialty drugs. Are outcomes-based agreements a realistic framework for anti-amyloid therapies, and what outcome metrics would actually be feasible and meaningful for payers to track?

What would a well-designed managed care benefit for Alzheimer's disease look like — one that gets the right patients treated in time without creating unsustainable administrative burden on practices?

Led by the moderator, the expert neurology and primary care panelists examined the gap between expanded coverage and real-world access. The panel agreed that Medicare has become far more permissive — lifting the national coverage determination (NCD) restriction on PET scans, broadening access to anti-amyloid therapies, and accepting blood-based biomarkers in lieu of PET or CSF to establish amyloid positivity — but that commercial payers continue to lag significantly behind. Dylan Gallacher, PA-C, and Jennifer Woodward, MD, MPH, both described treatment denials and coverage delays for commercially insured patients, cautioning that relying on the Medicare annual wellness visit as the primary detection pathway leaves younger, non-Medicare patients underserved. Joshua Oaks, MD, shared the case of a 58-year-old patient with confirmed biomarker-positive Alzheimer's disease whose commercial insurer refused to cover treatment, noting that roughly 200,000 Americans under 65 live with the disease and urging commercial payers to close this gap.

Throughout the conversation, the experts provided a comprehensive reflection on the field and the factors that may shape how clinicians approach care moving forward.

In the next episode, 'The Next Frontier: Subcutaneous Therapy and the Future of Alzheimer's Disease Access,' panelists continue their discussion on Alzheimer's disease and highlight how subcutaneous dosing and remote monitoring could extend treatment access to underserved and rural communities.