TRICARE addressed a critical coverage gap by approving provisional coverage of a new type of drug for the treatment of early stage Alzheimer’s disease – a move supported by MOAA and fellow key military and veterans groups.

For up to the next five years, TRICARE will cover Food and Drug Administration (FDA)-approved monoclonal antibodies (MABs) lecanemab (brand name Leqembi) and donanemab (brand name Kisunla), for the treatment of Alzheimer’s disease in patients with mild cognitive impairment or in the mild dementia stage of the disease. The assistant secretary of defense for health affairs approved the change last October.

MOAA has worked to fix this coverage gap since the 118th Congress alongside stakeholders like The Military Coalition (TMC) – a group of military and veterans service organizations representing nearly 5.5 million members combined.

[MEMBER-EXCLUSIVE MOAA PUBLICATION: Transitioning Into Medicare and TRICARE For Life]

Reimbursement Options

MOAA has confirmed reimbursements for Leqembi and Kisunla are in effect. Beneficiaries whose claims were paid by Medicare but denied by TRICARE should contact the WPS customer service team for assistance in ensuring those claims are now processed under TRICARE For Life. 

There is no need to submit a corrected claim – simply reach out with details on the affected claims for reconsideration. 

You can contact the WPS customer service team through the TRICARE4u.com portal or by calling (866) 773-0404. Coverage is retroactive to Oct. 23, 2024, the provisional decision approval date.

Filling the Gap

Several impacted MOAA members initially alerted MOAA to this coverage gap; we appreciate their outreach, along with the support of members who reached out to their lawmakers on this issue via our Legislative Action Center.

Before the provisional coverage decision, TRICARE’s outdated policy excluded coverage of MABs, including Leqembi, even though the drug has had full FDA approval since July 6, 2023. The Centers for Medicare and Medicaid Services (CMS) approved Medicare coverage for Leqembi, and federal employees have had access to Leqembi under the BlueCross BlueShield Federal Employee Program, a key benchmark plan for evaluating TRICARE coverage.  

[RELATED: TRICARE Contacts: Who to Call With Coverage Changes and Problems]

Treatment for Alzheimer’s disease is most effective when administered early – delays can result in irreversible disease progression – which made this prolonged TRICARE coverage gap particularly egregious. 

MOAA will continue its work to ensure TRICARE coverage keeps pace with plans offered in the federal and civilian sectors, protecting the value of your earned benefit and preserving your access to world-class care. Learn more about our work on access-to-care issues as part of next month’s Advocacy in Action event – if you’ve faced access barriers, reach out to MOAA and share your story.